Provider Demographics
NPI:1477443208
Name:KEIERLEBER, ETHAN ISAAC
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ISAAC
Last Name:KEIERLEBER
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 1:8529 W FAIRVIEW AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8589
Mailing Address - Country:US
Mailing Address - Phone:205-718-4251
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-584-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician