Provider Demographics
NPI:1114273372
Name:KETTERHAGEN, ADAM ROBERT (PT DPT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:ROBERT
Last Name:KETTERHAGEN
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:5340 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-638-1272
Practice Address - Fax:262-638-1287
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12113-24225100000X
AZ9895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist