Provider Demographics
NPI:1447243159
Name:KLETTE-KETCHUM, MARIA (MSW, LCSW, ACSW,SAP)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:KLETTE-KETCHUM
Suffix:
Gender:F
Credentials:MSW, LCSW, ACSW,SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76230 HIGHWAY 1083
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-4050
Mailing Address - Country:US
Mailing Address - Phone:985-624-2266
Mailing Address - Fax:985-898-0945
Practice Address - Street 1:1350 PARK DR
Practice Address - Street 2:STE A
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3205
Practice Address - Country:US
Practice Address - Phone:985-624-2266
Practice Address - Fax:985-898-0945
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5S295Medicare ID - Type Unspecified