Healthcare Provider Details

I. General information

NPI: 1578392346
Provider Name (Legal Business Name): ETHAN DEYHLE OTD, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 CORNHUSKER HWY STE 200
LINCOLN NE
68504-1509
US

IV. Provider business mailing address

4800 HOLDREGE ST APT 506
LINCOLN NE
68504-3180
US

V. Phone/Fax

Practice location:
  • Phone: 402-904-4474
  • Fax:
Mailing address:
  • Phone: 224-500-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2918
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: