Provider Demographics
NPI:1699241281
Name:SCHAFFER, ETHAN CHARLES (MA)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:CHARLES
Last Name:SCHAFFER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 VIA LARGA VIS
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-4022
Mailing Address - Country:US
Mailing Address - Phone:760-845-3084
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 202
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5736
Practice Address - Country:US
Practice Address - Phone:760-758-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALPCC18090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health