Provider Demographics
NPI:1194366724
Name:KETTON, CHELSIE (LCPC)
Entity Type:Individual
Prefix:
First Name:CHELSIE
Middle Name:
Last Name:KETTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-4374
Mailing Address - Country:US
Mailing Address - Phone:815-847-9197
Mailing Address - Fax:
Practice Address - Street 1:2218 CUSTER AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-4374
Practice Address - Country:US
Practice Address - Phone:815-847-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health