Healthcare Provider Details

I. General information

NPI: 1518886613
Provider Name (Legal Business Name): ETHAN MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 RUTH HENTZ AVE BLDG B
PANAMA CITY FL
32405-2258
US

IV. Provider business mailing address

827 JEREMY LN
PANAMA CITY FL
32405-3929
US

V. Phone/Fax

Practice location:
  • Phone: 850-628-1713
  • Fax:
Mailing address:
  • Phone: 850-628-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-485677
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: