Provider Demographics
NPI:1063756146
Name:KETTERER, LISE (COTA NHA)
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:KETTERER
Suffix:
Gender:F
Credentials:COTA NHA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CLOUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3578 HARTSEL DR # E-335
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-2103
Mailing Address - Country:US
Mailing Address - Phone:949-813-8637
Mailing Address - Fax:
Practice Address - Street 1:2750 KITTYHAWK RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1441
Practice Address - Country:US
Practice Address - Phone:949-813-8637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000024224Z00000X
CA2214224Z00000X
CONHA.0002857376G00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No376G00000XNursing Service Related ProvidersNursing Home Administrator