Provider Demographics
NPI:1104225010
Name:KETTER, REBECCA GAYLE (MA, ED S)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GAYLE
Last Name:KETTER
Suffix:
Gender:F
Credentials:MA, ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 COCKRELLS RUN RD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8833
Mailing Address - Country:US
Mailing Address - Phone:740-285-6778
Mailing Address - Fax:740-259-2337
Practice Address - Street 1:2114 COCKRELLS RUN RD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8833
Practice Address - Country:US
Practice Address - Phone:740-285-6778
Practice Address - Fax:740-259-2337
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOHI375410103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist