Provider Demographics
NPI:1306180377
Name:KETTER, MARTA ELISA (SLP MS)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:ELISA
Last Name:KETTER
Suffix:
Gender:F
Credentials:SLP MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 KRYSHER RD
Mailing Address - Street 2:
Mailing Address - City:MAKANDA
Mailing Address - State:IL
Mailing Address - Zip Code:62958-2423
Mailing Address - Country:US
Mailing Address - Phone:618-967-3828
Mailing Address - Fax:
Practice Address - Street 1:306 W MILL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2727
Practice Address - Country:US
Practice Address - Phone:618-529-3060
Practice Address - Fax:618-529-3847
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004438235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist