Provider Demographics
NPI:1508674300
Name:SHUFORD, ETHAN DANIEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DANIEL
Last Name:SHUFORD
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 1:163 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-1830
Mailing Address - Country:US
Mailing Address - Phone:828-261-6462
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCE CT
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9445
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-25
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician