Provider Demographics
NPI:1487188231
Name:KETTENHOFEN, TATIANA HELENE (LMT)
Entity Type:Individual
Prefix:MS
First Name:TATIANA
Middle Name:HELENE
Last Name:KETTENHOFEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 RITCHIE HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3919
Mailing Address - Country:US
Mailing Address - Phone:443-474-3631
Mailing Address - Fax:410-874-0131
Practice Address - Street 1:692 RITCHIE HWY STE 104
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3919
Practice Address - Country:US
Practice Address - Phone:443-474-3631
Practice Address - Fax:410-874-0131
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist