Provider Demographics
NPI:1811646078
Name:DULTZ, ETHAN JOHN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOHN
Last Name:DULTZ
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 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:281-826-3382
Mailing Address - Fax:425-491-7683
Practice Address - Street 1:9734 OLIVE BLVD
Practice Address - Street 2:UNIT 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3253
Practice Address - Country:US
Practice Address - Phone:314-932-2402
Practice Address - Fax:314-666-9770
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician