Provider Demographics
NPI:1730230038
Name:HARRIS, ETHAN G (MSW)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:G
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MERRIAM ST
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1348
Mailing Address - Country:US
Mailing Address - Phone:781-891-5797
Mailing Address - Fax:
Practice Address - Street 1:240 MERRIAM ST
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1348
Practice Address - Country:US
Practice Address - Phone:781-891-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1011831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO2767Medicare UPIN