Provider Demographics
NPI:1851052922
Name:ROBERTS, ETHAN C
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:C
Last Name:ROBERTS
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 1:21 BRADFORD RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-4249
Mailing Address - Country:US
Mailing Address - Phone:650-740-5198
Mailing Address - Fax:
Practice Address - Street 1:1 ARARAT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-3328
Practice Address - Country:US
Practice Address - Phone:508-341-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician