Provider Demographics
NPI:1063168144
Name:DIKE, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DIKE
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 1:18 W CYPRESS PL
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-2258
Mailing Address - Country:US
Mailing Address - Phone:925-470-0331
Mailing Address - Fax:
Practice Address - Street 1:877 YGNACIO VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-3897
Practice Address - Country:US
Practice Address - Phone:925-482-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty