Provider Demographics
NPI:1356631949
Name:KETTLER, CHAD FREDERICK (MPT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:FREDERICK
Last Name:KETTLER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 NOLL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-7606
Mailing Address - Country:US
Mailing Address - Phone:717-391-9920
Mailing Address - Fax:717-391-9925
Practice Address - Street 1:2125 NOLL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-7606
Practice Address - Country:US
Practice Address - Phone:717-391-9920
Practice Address - Fax:717-391-9925
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012978L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2607761OtherHIGHMARK PA BS
PA1025786840001Medicaid
PA218174YENFMedicare PIN