Provider Demographics
NPI:1235994773
Name:KETTERER, KATHERINE ELLICE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELLICE
Last Name:KETTERER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 W PARK RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-4336
Mailing Address - Country:US
Mailing Address - Phone:561-232-0328
Mailing Address - Fax:
Practice Address - Street 1:2100 E HALLANDALE BEACH BLVD STE 101B
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-3722
Practice Address - Country:US
Practice Address - Phone:786-846-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA33234225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant