Provider Demographics
NPI:1245991066
Name:DECKER, ETHAN HARRISON
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:HARRISON
Last Name:DECKER
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:FRONTIER BEHAVIORAL HEALTH, 107 S. DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:
Practice Address - Street 1:FRONTIER BEHAVIORAL HEALTH, 505 E NORTH FOOTHILLS DR.
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
WACG61263436101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program