Provider Demographics
NPI:1053764886
Name:WARANCH, ETHAN (PSYD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WARANCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 SW MORRISON ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1945
Mailing Address - Country:US
Mailing Address - Phone:503-352-2400
Mailing Address - Fax:503-352-2403
Practice Address - Street 1:12636 SE STARK ST BLDG J
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-253-4600
Practice Address - Fax:503-253-4605
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-16
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3654103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty