Provider Demographics
NPI:1710389556
Name:VANDERMARK, ETHAN KEYES
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:KEYES
Last Name:VANDERMARK
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 1:113 MARKET ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3211
Mailing Address - Country:US
Mailing Address - Phone:603-502-3714
Mailing Address - Fax:
Practice Address - Street 1:113 MARKET ST
Practice Address - Street 2:APT. 2
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3211
Practice Address - Country:US
Practice Address - Phone:603-502-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor