Provider Demographics
NPI:1306015656
Name:KETTER, MYRON EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:EDWARD
Last Name:KETTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CLEVELAND ST STE C
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3564
Mailing Address - Country:US
Mailing Address - Phone:706-994-5360
Mailing Address - Fax:706-237-2571
Practice Address - Street 1:98 CLEVELAND ST STE C
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3564
Practice Address - Country:US
Practice Address - Phone:706-994-5360
Practice Address - Fax:706-237-2571
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109571041C0700X
FLSW 85511041C0700X
GA0053681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1306015656Medicaid
GA1306015656Medicaid
GA003171972BMedicaid
FL1306015656Medicaid
SC1306015656Medicaid
FL1306015656Medicare NSC
SC1306015656Medicare NSC
VT2013886574Medicaid
SC1306015656Medicaid