Provider Demographics
NPI:1093971152
Name:KETELSEN, CASEY (DPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KETELSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:2900 US HIGHWAY 12 SUITE J
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-0362
Mailing Address - Country:US
Mailing Address - Phone:815-675-0699
Mailing Address - Fax:815-675-0689
Practice Address - Street 1:2900 N US HIGHWAY 12 STE J
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-8322
Practice Address - Country:US
Practice Address - Phone:815-675-0699
Practice Address - Fax:815-675-0689
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist