Provider Demographics
NPI:1154867042
Name:KETTLER, TISH S (MSPT)
Entity Type:Individual
Prefix:
First Name:TISH
Middle Name:S
Last Name:KETTLER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 CLAYTON RD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1328
Mailing Address - Country:US
Mailing Address - Phone:314-283-6936
Mailing Address - Fax:
Practice Address - Street 1:7700 CLAYTON RD
Practice Address - Street 2:SUITE 311
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1328
Practice Address - Country:US
Practice Address - Phone:314-283-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114355225100000X
IL070.010801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist