Provider Demographics
NPI:1356009443
Name:KETSOGLOU, EVE-MICHELLE
Entity Type:Individual
Prefix:
First Name:EVE-MICHELLE
Middle Name:
Last Name:KETSOGLOU
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 1:2550 STAG RUN BLVD APT 833
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1842
Mailing Address - Country:US
Mailing Address - Phone:845-729-2488
Mailing Address - Fax:
Practice Address - Street 1:10763 64TH CT N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-2417
Practice Address - Country:US
Practice Address - Phone:727-504-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician