Provider Demographics
NPI:1336270578
Name:KETTENBACH, VIRGINIA KAY (PT,PHD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:KAY
Last Name:KETTENBACH
Suffix:
Gender:F
Credentials:PT,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 CHATELET DR.
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-1334
Mailing Address - Country:US
Mailing Address - Phone:314-977-8543
Mailing Address - Fax:314-977-8513
Practice Address - Street 1:3437 CAROLINE ST., ROOM 1030
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-977-8543
Practice Address - Fax:314-977-8513
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist