Healthcare Provider Details

I. General information

NPI: 1821929324
Provider Name (Legal Business Name): ETHAN CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 LAKESIDE DR STE 200
RENO NV
89509-5293
US

IV. Provider business mailing address

1052 WATT ST APT C
RENO NV
89509-2869
US

V. Phone/Fax

Practice location:
  • Phone: 775-895-0712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: