Provider Demographics
NPI:1538692512
Name:KETTLEWELL, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:KETTLEWELL
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 1:3419 VIA LIDO
Mailing Address - Street 2:310
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:949-723-2388
Mailing Address - Fax:
Practice Address - Street 1:1601 W BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4527
Practice Address - Country:US
Practice Address - Phone:949-723-2388
Practice Address - Fax:949-723-1288
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor