Provider Demographics
NPI:1124432752
Name:PERRY, ETHAN (LMHC, CASAC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 CHANNINGVILLE RD.
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1133 ROUTE 55
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5051
Practice Address - Country:US
Practice Address - Phone:845-204-3436
Practice Address - Fax:845-298-8000
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18 004757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health