Provider Demographics
NPI:1831898022
Name:WEINFELD, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WEINFELD
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 1:6687 ALDERLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3858
Mailing Address - Country:US
Mailing Address - Phone:248-914-7229
Mailing Address - Fax:
Practice Address - Street 1:6687 ALDERLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3858
Practice Address - Country:US
Practice Address - Phone:248-914-7229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator