Provider Demographics
NPI:1629374301
Name:KETTERING, YVONNE PEREZ (LAC)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:PEREZ
Last Name:KETTERING
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:YVONNE
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:8701 SHOAL CREEK BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6864
Mailing Address - Country:US
Mailing Address - Phone:512-801-2453
Mailing Address - Fax:512-420-8573
Practice Address - Street 1:8701 SHOAL CREEK BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6864
Practice Address - Country:US
Practice Address - Phone:512-801-2453
Practice Address - Fax:512-420-8573
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTXAC00847171100000X
TXMT107098172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0031DGOtherBLUE CROSS BLUE SHIELD
TX0944746-02Medicaid
TX0944746-02Medicaid