Provider Demographics
NPI:1225174220
Name:KETTERSON, TIMOTHY USHER JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:USHER
Last Name:KETTERSON
Suffix:JR
Gender:M
Credentials:PHD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4965 SW 91ST TER
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8149
Mailing Address - Country:US
Mailing Address - Phone:352-337-0551
Mailing Address - Fax:352-374-2166
Practice Address - Street 1:4965 SW 91ST TER
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-8149
Practice Address - Country:US
Practice Address - Phone:352-337-0551
Practice Address - Fax:352-374-2166
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPY7453103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling