Provider Demographics
NPI:1922543396
Name:EMERY, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:EMERY
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 1:1080 E GUN HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3742
Mailing Address - Country:US
Mailing Address - Phone:718-653-1117
Mailing Address - Fax:718-653-2112
Practice Address - Street 1:1080 E GUN HILL RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3742
Practice Address - Country:US
Practice Address - Phone:718-653-1117
Practice Address - Fax:718-653-2112
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28915101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)