Provider Demographics
NPI:1568034452
Name:ROCKWELL-KETTLES, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:ROCKWELL-KETTLES
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 1:510 CLINTON SQ
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1700
Mailing Address - Country:US
Mailing Address - Phone:585-204-0381
Mailing Address - Fax:973-253-4500
Practice Address - Street 1:510 CLINTON SQ
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1700
Practice Address - Country:US
Practice Address - Phone:585-200-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP108976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1568034452OtherINSURANCE