Provider Demographics
NPI:1508214453
Name:KETCHUM, ANNABELLE LOUISE
Entity Type:Individual
Prefix:MISS
First Name:ANNABELLE
Middle Name:LOUISE
Last Name:KETCHUM
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 1:12020 96TH AVE NE APT 330
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6238
Mailing Address - Country:US
Mailing Address - Phone:412-779-7923
Mailing Address - Fax:
Practice Address - Street 1:1022 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2018
Practice Address - Country:US
Practice Address - Phone:425-349-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA163648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist