Provider Demographics
NPI:1922457688
Name:BREWER, ETHAN DEWEY (BCABA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:DEWEY
Last Name:BREWER
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 SAM RITTENBERG BLVD
Mailing Address - Street 2:UNIT 1-B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4194
Mailing Address - Country:US
Mailing Address - Phone:888-547-2250
Mailing Address - Fax:
Practice Address - Street 1:2580 LIN-DO CT
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1832
Practice Address - Country:US
Practice Address - Phone:803-905-4427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-16-7040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst