Provider Demographics
NPI:1245660281
Name:ABERCROMBIE, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ABERCROMBIE
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 1:14005 SPYGLASS CIR
Mailing Address - Street 2:
Mailing Address - City:CHOWCHILLA
Mailing Address - State:CA
Mailing Address - Zip Code:93610-7903
Mailing Address - Country:US
Mailing Address - Phone:559-201-9452
Mailing Address - Fax:
Practice Address - Street 1:14005 SPYGLASS CIR
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-7903
Practice Address - Country:US
Practice Address - Phone:559-201-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21994103TC0700X
NM1236103TC0700X
AZ3951103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical