Provider Demographics
NPI:1023902590
Name:DAVIS, ETHAN LANE
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:LANE
Last Name:DAVIS
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 1:177 MOUSE CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3838
Mailing Address - Country:US
Mailing Address - Phone:888-963-2228
Mailing Address - Fax:
Practice Address - Street 1:177 MOUSE CREEK RD NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3838
Practice Address - Country:US
Practice Address - Phone:888-963-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-07
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-25-442247106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician