Provider Demographics
NPI:1730928086
Name:WALTZ, ETHAN KYLE (LMSW, LMT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:KYLE
Last Name:WALTZ
Suffix:
Gender:M
Credentials:LMSW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 VILLAGE LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-4317
Mailing Address - Country:US
Mailing Address - Phone:615-613-1562
Mailing Address - Fax:
Practice Address - Street 1:282 VILLAGE LAKE CIR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-4317
Practice Address - Country:US
Practice Address - Phone:615-613-1562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN014172104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker