Provider Demographics
NPI:1013310929
Name:KETCHAM, KIMBERLEY-RAE (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY-RAE
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 ROCKBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-9559
Mailing Address - Country:US
Mailing Address - Phone:937-726-1542
Mailing Address - Fax:937-552-9121
Practice Address - Street 1:1605 ROCKBRIDGE CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-9559
Practice Address - Country:US
Practice Address - Phone:937-726-1542
Practice Address - Fax:937-552-9121
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP3973235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist