Provider Demographics
NPI:1215187505
Name:DEMIENTIEFF, KATHLEEN KETZLER (TC, CDC1)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KETZLER
Last Name:DEMIENTIEFF
Suffix:
Gender:F
Credentials:TC, CDC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 EVERGREEN ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4306
Mailing Address - Country:US
Mailing Address - Phone:907-451-8164
Mailing Address - Fax:
Practice Address - Street 1:1027 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4306
Practice Address - Country:US
Practice Address - Phone:907-451-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3432101YA0400X
AK2920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)