Provider Demographics
NPI:1043428287
Name:KETTERHAGEN, KELLY JO (MSOTR)
Entity Type:Individual
Prefix:
First Name:KELLY JO
Middle Name:
Last Name:KETTERHAGEN
Suffix:
Gender:F
Credentials:MSOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 AUTUMN TRL
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53076-9419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N84W17049 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2701
Practice Address - Country:US
Practice Address - Phone:262-255-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4355-026225XH1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40894900Medicaid