Provider Demographics
NPI:1154679652
Name:KETTELER, MARY PATRICIA (HIS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:KETTELER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8044 MONTGOMERY RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-2919
Mailing Address - Country:US
Mailing Address - Phone:513-792-4065
Mailing Address - Fax:513-792-2222
Practice Address - Street 1:8044 MONTGOMERY RD
Practice Address - Street 2:SUITE 700
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2919
Practice Address - Country:US
Practice Address - Phone:513-792-4065
Practice Address - Fax:513-792-2222
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02707237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$-01OtherBUREAU OF WORKERS' COMPENSATION