Provider Demographics
NPI:1619379112
Name:KETTERIDGE, SHANNA (LPC, MC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:KETTERIDGE
Suffix:
Gender:F
Credentials:LPC, MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:
Practice Address - Street 1:221 E 29TH ST STE 101
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2721
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0013006101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional