Provider Demographics
NPI:1194126433
Name:KETCHUM-FISH, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KETCHUM-FISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7665 US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54847-4690
Mailing Address - Country:US
Mailing Address - Phone:715-685-2200
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1639
Practice Address - Country:US
Practice Address - Phone:715-685-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6395-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional