Provider Demographics
NPI:1184306086
Name:GIDDENS, ETHAN EDUARDO
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:EDUARDO
Last Name:GIDDENS
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 1:3797 MOUNT AINSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3214
Mailing Address - Country:US
Mailing Address - Phone:619-806-2191
Mailing Address - Fax:
Practice Address - Street 1:3797 MOUNT AINSWORTH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3214
Practice Address - Country:US
Practice Address - Phone:619-806-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician