Provider Demographics
NPI:1326816208
Name:KETTENBURG, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:KETTENBURG
Suffix:
Gender:F
Credentials:
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 99
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:PA
Mailing Address - Zip Code:18833-0099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 S ELMER AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2019
Practice Address - Country:US
Practice Address - Phone:607-221-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician