Provider Demographics
NPI:1023424249
Name:KETCHUM, KATHRYN (COTA/L)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2097
Mailing Address - Country:US
Mailing Address - Phone:860-678-9755
Mailing Address - Fax:
Practice Address - Street 1:33 CONE AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4822
Practice Address - Country:US
Practice Address - Phone:203-238-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000534224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant