Healthcare Provider Details

I. General information

NPI: 1518870625
Provider Name (Legal Business Name): ETHAN JOHN FAIGAO MONTESA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N BRAND BLVD STE 100
GLENDALE CA
91203-3240
US

IV. Provider business mailing address

3991 COLLEGE CREST DR
LOS ANGELES CA
90065-4313
US

V. Phone/Fax

Practice location:
  • Phone: 747-286-2600
  • Fax:
Mailing address:
  • Phone: 310-592-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: