Provider Demographics
NPI:1659867307
Name:KETCHUM, MARY ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 STIDHAM RD
Mailing Address - Street 2:
Mailing Address - City:MATHISTON
Mailing Address - State:MS
Mailing Address - Zip Code:39752
Mailing Address - Country:US
Mailing Address - Phone:662-425-1051
Mailing Address - Fax:662-327-1970
Practice Address - Street 1:100 STARR AVE STE K
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4032
Practice Address - Country:US
Practice Address - Phone:662-425-1051
Practice Address - Fax:662-200-5960
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS069799252Medicaid