Individual
ETHAN WILD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
43 ELIZABETH ST, PEMBERTON, NJ 08068-1232
(609) 316-0195
Mailing address
PO BOX 253, SKILLMAN, NJ 08558-0253
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
RBT-20-126237
NJ
Other
Enumeration date
07/13/2020
Last updated
07/13/2020
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