Provider Demographics
NPI:1194456731
Name:KETSCHKE, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:KETSCHKE
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 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:
Practice Address - Street 1:8002 KEW GARDENS RD FL 4
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3604
Practice Address - Country:US
Practice Address - Phone:347-954-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist