Healthcare Provider Details

I. General information

NPI: 1245991066
Provider Name (Legal Business Name): ETHAN HARRISON DECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FRONTIER BEHAVIORAL HEALTH, 505 E NORTH FOOTHILLS DR.
SPOKANE WA
99207
US

IV. Provider business mailing address

FRONTIER BEHAVIORAL HEALTH, 107 S. DIVISION STREET
SPOKANE WA
99202
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4651
  • Fax:
Mailing address:
  • Phone: 509-838-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61263436
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: