Provider Demographics
NPI:1750032256
Name:WHEELER, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WHEELER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 CEDAR BAY PT APT 202
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-6539
Mailing Address - Country:US
Mailing Address - Phone:814-777-9759
Mailing Address - Fax:
Practice Address - Street 1:2608 CEDAR BAY PT APT 202
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-6539
Practice Address - Country:US
Practice Address - Phone:814-777-9759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty