Provider Demographics
NPI:1679622971
Name:KETTLE, TRACI ALENE
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:ALENE
Last Name:KETTLE
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 1:5261 GOLDENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4129
Mailing Address - Country:US
Mailing Address - Phone:805-312-4759
Mailing Address - Fax:
Practice Address - Street 1:260 W 4TH ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-5908
Practice Address - Country:US
Practice Address - Phone:805-486-9405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health