Provider Demographics
NPI:1952171175
Name:KETCHAM, KELLY (MA, LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08722-4535
Mailing Address - Country:US
Mailing Address - Phone:732-600-4362
Mailing Address - Fax:
Practice Address - Street 1:516 BAY AVE STE 3
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08742-2554
Practice Address - Country:US
Practice Address - Phone:848-235-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00761700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health