Provider Demographics
NPI:1972852150
Name:KETNER, CHARLES LEE
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:KETNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 NW KINYON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-215-3435
Mailing Address - Fax:
Practice Address - Street 1:5807 NW KINYON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-4629
Practice Address - Country:US
Practice Address - Phone:580-215-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor