Provider Demographics
NPI:1679704472
Name:KETTLE, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KETTLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 ALHAMBRA BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5242
Mailing Address - Country:US
Mailing Address - Phone:916-731-7951
Mailing Address - Fax:
Practice Address - Street 1:1201 ALHAMBRA BLVD STE 340
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5242
Practice Address - Country:US
Practice Address - Phone:916-731-7951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29461103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical