Provider Demographics
NPI:1467265389
Name:STUCKER, ETHAN LOGAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:LOGAN
Last Name:STUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:STUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 CAMPUS VIEW RD APT 5
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6337
Mailing Address - Country:US
Mailing Address - Phone:303-242-4422
Mailing Address - Fax:
Practice Address - Street 1:1720 BASSETT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6569
Practice Address - Country:US
Practice Address - Phone:507-682-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician