Provider Demographics
NPI:1184676637
Name:KETTERMAN, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:KETTERMAN
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 1:227 S PENDLETON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3047
Mailing Address - Country:US
Mailing Address - Phone:864-855-7030
Mailing Address - Fax:864-855-7019
Practice Address - Street 1:227 S PENDLETON ST
Practice Address - Street 2:SUITE B
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3047
Practice Address - Country:US
Practice Address - Phone:864-855-7030
Practice Address - Fax:864-855-7019
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1654Medicaid
Q482656600Medicare PIN
SCTH1654Medicaid
Q334326600Medicare PIN