Healthcare Provider Details

I. General information

NPI: 1356272454
Provider Name (Legal Business Name): ETHAN ISAAC PEARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12057 HIGHWAY 9
BOULDER CREEK CA
95006-9406
US

IV. Provider business mailing address

12178 HETCH HECHY DR
RANCHO CORDOVA CA
95742-8235
US

V. Phone/Fax

Practice location:
  • Phone: 408-663-6652
  • Fax:
Mailing address:
  • Phone: 972-971-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-83098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: