Provider Demographics
NPI:1679622971
Name:KETTLE, TRACI ALENE
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:ALENE
Last Name:KETTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 GOLDENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4129
Mailing Address - Country:US
Mailing Address - Phone:805-312-4759
Mailing Address - Fax:
Practice Address - Street 1:211 S WOODRUFF AVE STE A3
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4865
Practice Address - Country:US
Practice Address - Phone:208-524-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2025-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist