Provider Demographics
NPI:1972872216
Name:KETCHEL, CAROLYN N (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:N
Last Name:KETCHEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:N
Other - Last Name:KETHCEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0007
Mailing Address - Country:US
Mailing Address - Phone:850-243-1302
Mailing Address - Fax:850-301-0671
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1972
Practice Address - Country:US
Practice Address - Phone:850-243-1302
Practice Address - Fax:850-301-0671
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW47091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 4709OtherSTATE LIENSE
FLSW 4709OtherSTATE LIENSE