Provider Demographics
NPI:1275877086
Name:CAROLYN N. KETCHEL, P.A.
Entity Type:Organization
Organization Name:CAROLYN N. KETCHEL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KETCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-243-1302
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0007
Mailing Address - Country:US
Mailing Address - Phone:850-243-1302
Mailing Address - Fax:850-301-0671
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1973
Practice Address - Country:US
Practice Address - Phone:850-243-1302
Practice Address - Fax:850-301-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW47091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GW646AMedicare PIN