Provider Demographics
NPI:1407849680
Name:KETTERING, RANDY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:KETTERING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W COLLEGE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1900
Mailing Address - Country:US
Mailing Address - Phone:847-934-8475
Mailing Address - Fax:
Practice Address - Street 1:11 W COLLEGE DR
Practice Address - Street 2:SUITE B
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1900
Practice Address - Country:US
Practice Address - Phone:847-934-8475
Practice Address - Fax:847-934-8475
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical