Provider Demographics
NPI:1609376607
Name:KETCHAM, KAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:KETCHAM
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 1:1935 BLUE ROCK DR APT 301
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5196
Mailing Address - Country:US
Mailing Address - Phone:339-832-7716
Mailing Address - Fax:
Practice Address - Street 1:50 ALDRIN RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4827
Practice Address - Country:US
Practice Address - Phone:617-848-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst