Healthcare Provider Details

I. General information

NPI: 1184554263
Provider Name (Legal Business Name): ETHAN MINKERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 DEERFIELD PKWY
MILTON GA
30004-6119
US

IV. Provider business mailing address

5050 RESEARCH CT STE 125
SUWANEE GA
30024-5573
US

V. Phone/Fax

Practice location:
  • Phone: 404-795-7263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: