Provider Demographics
NPI:1063056778
Name:WEBB, ETHAN DOUGLAS JOE
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DOUGLAS JOE
Last Name:WEBB
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 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:269-967-5039
Mailing Address - Fax:
Practice Address - Street 1:1800 ATRIUM PKWY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-4837
Practice Address - Country:US
Practice Address - Phone:707-310-7486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist