Provider Demographics
NPI:1649710211
Name:EPPERSON, ETHAN EVAN (MS LBP)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:EVAN
Last Name:EPPERSON
Suffix:
Gender:M
Credentials:MS LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 SW SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1531
Mailing Address - Country:US
Mailing Address - Phone:580-585-6656
Mailing Address - Fax:580-585-6657
Practice Address - Street 1:1010 SW SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1531
Practice Address - Country:US
Practice Address - Phone:580-585-6656
Practice Address - Fax:580-585-6657
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0139101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health