Healthcare Provider Details

I. General information

NPI: 1649053000
Provider Name (Legal Business Name): ETHAN HUFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 HOLLISTER CT
SAINT PETERS MO
63376-7837
US

IV. Provider business mailing address

94 HOLLISTER CT
SAINT PETERS MO
63376-7837
US

V. Phone/Fax

Practice location:
  • Phone: 314-287-1825
  • Fax: 314-338-4159
Mailing address:
  • Phone: 314-287-1825
  • Fax: 314-338-4159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: