Provider Demographics
NPI:1609180041
Name:KETCHAM, DAVID SCOTT (BA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
Last Name:KETCHAM
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SONORA CT
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5115
Mailing Address - Country:US
Mailing Address - Phone:307-324-7156
Mailing Address - Fax:307-328-1651
Practice Address - Street 1:143 SONORA CT
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5115
Practice Address - Country:US
Practice Address - Phone:307-324-7156
Practice Address - Fax:307-328-1651
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAP -19101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)