Provider Demographics
NPI:1912236845
Name:KETTLER, JOHN THOMAS (CSAC, LPC-IT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:KETTLER
Suffix:
Gender:M
Credentials:CSAC, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3632
Mailing Address - Country:US
Mailing Address - Phone:262-548-7666
Mailing Address - Fax:262-548-7656
Practice Address - Street 1:500 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3632
Practice Address - Country:US
Practice Address - Phone:262-548-7666
Practice Address - Fax:262-548-7656
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1016-226101YP2500X
WI15594-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional