Provider Demographics
NPI:1902672496
Name:MCGILL, ETHAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:CHRISTOPHER
Last Name:MCGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3954 N KICKAPOO AVE STE 1-3
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1698
Mailing Address - Country:US
Mailing Address - Phone:405-857-8280
Mailing Address - Fax:
Practice Address - Street 1:3954 N KICKAPOO AVE STE 1-3
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1698
Practice Address - Country:US
Practice Address - Phone:405-857-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23-316745106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician