Provider Demographics
NPI:1265904429
Name:KETTERER, SUELLEN LOVELL (MA)
Entity type:Individual
Prefix:
First Name:SUELLEN
Middle Name:LOVELL
Last Name:KETTERER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522-1350
Mailing Address - Country:US
Mailing Address - Phone:610-944-0445
Mailing Address - Fax:
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-1323
Practice Address - Country:US
Practice Address - Phone:610-944-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional