Provider Demographics
NPI:1073973301
Name:MEAD, KETHA
Entity Type:Individual
Prefix:
First Name:KETHA
Middle Name:
Last Name:MEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 TROY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3995
Mailing Address - Country:US
Mailing Address - Phone:208-882-6912
Mailing Address - Fax:208-882-8575
Practice Address - Street 1:1350 TROY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3995
Practice Address - Country:US
Practice Address - Phone:208-882-6912
Practice Address - Fax:208-882-8575
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist