Provider Demographics
NPI:1851428460
Name:BLISS, ETHAN (PHD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BLISS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MANDA DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-7853
Mailing Address - Country:US
Mailing Address - Phone:301-508-0102
Mailing Address - Fax:
Practice Address - Street 1:340 PARK AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4931
Practice Address - Country:US
Practice Address - Phone:301-663-1683
Practice Address - Fax:301-663-3792
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04888103TC0700X
IN20042437A103T00000X
IN39001937A101YM0800X
FLMH 7447101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health