Provider Demographics
NPI:1740798990
Name:KETTERING, KALEY (LCSW)
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:
Last Name:KETTERING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 30TH ST BOULDER
Mailing Address - Street 2:SUITE A PMB 496
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1630 30TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1044
Practice Address - Country:US
Practice Address - Phone:303-673-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099246721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCSW.09924672OtherDORA