Provider Demographics
NPI:1194492611
Name:WATTLEY, ETHAN SHERRERD
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:SHERRERD
Last Name:WATTLEY
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 1:6 TIFFANY DR
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-4256
Mailing Address - Country:US
Mailing Address - Phone:802-495-9853
Mailing Address - Fax:
Practice Address - Street 1:125 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8444
Practice Address - Country:US
Practice Address - Phone:802-448-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4737101YM0800X
VT097.0134209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health