Provider Demographics
NPI:1750792701
Name:KETTELSON, CAROLYN (CSCM)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KETTELSON
Suffix:
Gender:F
Credentials:CSCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9130 GALLERIA CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-4380
Mailing Address - Country:US
Mailing Address - Phone:230-449-4747
Mailing Address - Fax:239-790-5035
Practice Address - Street 1:9130 GALLERIA CT
Practice Address - Street 2:SUITE 103
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-4380
Practice Address - Country:US
Practice Address - Phone:230-449-4747
Practice Address - Fax:239-790-5035
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299994241171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator