Healthcare Provider Details

I. General information

NPI: 1003315730
Provider Name (Legal Business Name): ETHAN ZACHARY STEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 HOSPITAL LOOP
BERLIN VT
05602-9523
US

IV. Provider business mailing address

PO BOX 647
MONTPELIER VT
05601-0647
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-0591
  • Fax: 802-223-3667
Mailing address:
  • Phone: 802-229-0591
  • Fax: 802-223-3667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number097.0136720
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number156.0134408
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: