Provider Demographics
NPI:1255137881
Name:ETIEL, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ETIEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 BRICKELL BAY DR APT 204
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131-3601
Mailing Address - Country:US
Mailing Address - Phone:786-376-6606
Mailing Address - Fax:
Practice Address - Street 1:1430 BRICKELL BAY DR APT 204
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-3601
Practice Address - Country:US
Practice Address - Phone:786-376-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-412657106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty