Provider Demographics
NPI:1487025136
Name:KETCHUM, ROBERT CARL (CATC1)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CARL
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:CATC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 S STATE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4922
Mailing Address - Country:US
Mailing Address - Phone:951-791-3350
Mailing Address - Fax:951-791-3353
Practice Address - Street 1:1370 S STATE ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3350
Practice Address - Fax:951-791-3353
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAK1208311033101YA0400X
CAC054940518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)