Provider Demographics
NPI:1497571483
Name:MOUTNER, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:MOUTNER
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 1:22 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:JAMESBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-2529
Mailing Address - Country:US
Mailing Address - Phone:732-580-6578
Mailing Address - Fax:
Practice Address - Street 1:100 CRAIG RD STE 220
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8731
Practice Address - Country:US
Practice Address - Phone:732-913-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06389000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker