Provider Demographics
NPI:1881112217
Name:KETCHUP HALL, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:KETCHUP HALL
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 1:1025 VETERANS MEMORIAL HWY SE STE 660
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-7711
Mailing Address - Country:US
Mailing Address - Phone:678-696-1824
Mailing Address - Fax:
Practice Address - Street 1:1025 VETERANS MEMORIAL HWY SE STE 660
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-7711
Practice Address - Country:US
Practice Address - Phone:678-696-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006917101YP2500X
171W00000X, 390200000X
GALPC012859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171W00000XOther Service ProvidersContractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA6758Medicaid
CA7420Medicaid