Provider Demographics
NPI:1437641669
Name:KETCHERSID, TRUDDY
Entity Type:Individual
Prefix:
First Name:TRUDDY
Middle Name:
Last Name:KETCHERSID
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 64
Mailing Address - Street 2:
Mailing Address - City:VERDUNVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25649-0064
Mailing Address - Country:US
Mailing Address - Phone:304-752-8972
Mailing Address - Fax:304-752-8977
Practice Address - Street 1:710 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4015
Practice Address - Country:US
Practice Address - Phone:304-752-8972
Practice Address - Fax:304-752-8977
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor