Provider Demographics
NPI:1699275875
Name:KINGERY, ETHAN DANIEL (RBT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DANIEL
Last Name:KINGERY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:SIMLA
Mailing Address - State:CO
Mailing Address - Zip Code:80835-0504
Mailing Address - Country:US
Mailing Address - Phone:719-287-9801
Mailing Address - Fax:
Practice Address - Street 1:630 SOUTHPOINTE CT STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3800
Practice Address - Country:US
Practice Address - Phone:179-538-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician