MEDICARE: ETHAN JOHN DULTZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MO
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1811646078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN JOHN DULTZ

Provider Business Mailing Address
First Line	:	7500 SAN FELIPE ST STE 990
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-1708
Country	:	US
Telephone Number	:	281-826-3382
Fax Number	:	425-491-7683

Provider Business Practice Location Address
First Line	:	9734 OLIVE BLVD
Second Line	:	UNIT 101
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-3253
Country	:	US
Telephone Number	:	314-932-2402
Fax Number	:	314-666-9770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	10/13/2023

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