Provider Demographics
NPI:1235460767
Name:KETTERHAGEN, THERESA (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KETTERHAGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491471
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9471
Mailing Address - Country:US
Mailing Address - Phone:310-743-6649
Mailing Address - Fax:
Practice Address - Street 1:11677 SAN VICENTE BLVD
Practice Address - Street 2:STE 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5128
Practice Address - Country:US
Practice Address - Phone:310-743-6649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist