Provider Demographics
NPI:1194196048
Name:KETTLEWELL, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:KETTLEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 LEIDICH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2529
Mailing Address - Country:US
Mailing Address - Phone:517-819-0899
Mailing Address - Fax:
Practice Address - Street 1:1075 LEIDICH ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2529
Practice Address - Country:US
Practice Address - Phone:517-819-0899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501005129237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist