Provider Demographics
NPI:1871117283
Name:YAZELL, ETHAN WESLEY
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:WESLEY
Last Name:YAZELL
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 1:503 NE TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5613
Mailing Address - Country:US
Mailing Address - Phone:314-920-1403
Mailing Address - Fax:
Practice Address - Street 1:6330 NW KELLY DR STE A
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-4027
Practice Address - Country:US
Practice Address - Phone:816-469-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician