Provider Demographics
NPI:1356858351
Name:KETTNER, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:KETTNER
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 1:3128 BANJO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1689
Mailing Address - Country:US
Mailing Address - Phone:719-271-4614
Mailing Address - Fax:
Practice Address - Street 1:825 CITADEL DR E STE 250
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5488
Practice Address - Country:US
Practice Address - Phone:719-345-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019996101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional