Provider Demographics
NPI:1982938114
Name:KETTL, STEPHANIE M (MS, LPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:KETTL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2537
Mailing Address - Country:US
Mailing Address - Phone:307-421-9329
Mailing Address - Fax:307-635-3965
Practice Address - Street 1:821 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2537
Practice Address - Country:US
Practice Address - Phone:307-421-9329
Practice Address - Fax:307-635-3965
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1017101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor