Provider Demographics
NPI:1831578046
Name:KETTLE, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
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 1:4549 CHESTNUT MEADOWS BND
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7143
Mailing Address - Country:US
Mailing Address - Phone:785-249-4146
Mailing Address - Fax:
Practice Address - Street 1:3724 EXECUTIVE CENTER DR STE 220
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1638
Practice Address - Country:US
Practice Address - Phone:512-637-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-00911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist