Provider Demographics
NPI:1063870434
Name:KETTERMAN, KELLEY (BA, MED)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:
Last Name:KETTERMAN
Suffix:
Gender:F
Credentials:BA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1457
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:866-460-2997
Practice Address - Street 1:9702 STONESTREET RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-6808
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:866-460-2997
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
KY273669101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)