Provider Demographics
NPI:1699248781
Name:WARCHOL, ETHAN
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:WARCHOL
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 1:60 LAUREL RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-2430
Mailing Address - Country:US
Mailing Address - Phone:203-640-1742
Mailing Address - Fax:
Practice Address - Street 1:60 LAUREL RIDGE TRL
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-2430
Practice Address - Country:US
Practice Address - Phone:203-640-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011556225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist