Provider Demographics
NPI:1023427366
Name:KETCHAM, TRYSTIN A
Entity type:Individual
Prefix:
First Name:TRYSTIN
Middle Name:A
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRYSTIN
Other - Middle Name:
Other - Last Name:ENEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:13530 WEYBURNE DR
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-3648
Mailing Address - Country:US
Mailing Address - Phone:561-866-1935
Mailing Address - Fax:
Practice Address - Street 1:13530 WEYBURNE DR
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-3648
Practice Address - Country:US
Practice Address - Phone:561-866-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT294572251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics