Provider Demographics
NPI:1033617444
Name:KETAH, SHIRLEY (MS, CDC1)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:
Last Name:KETAH
Suffix:
Gender:F
Credentials:MS, CDC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11408 HERITAGE CT APT 7
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7778
Mailing Address - Country:US
Mailing Address - Phone:907-854-6997
Mailing Address - Fax:
Practice Address - Street 1:121 W FIREWEED LN
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2053
Practice Address - Country:US
Practice Address - Phone:907-865-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH101Y00000X
AK4099101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor