Provider Demographics
NPI:1194937359
Name:RANDY L. KETTERING PHD, PC
Entity type:Organization
Organization Name:RANDY L. KETTERING PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KETTERING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-934-8475
Mailing Address - Street 1:807 DAVIS ST UNIT 605
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4820
Mailing Address - Country:US
Mailing Address - Phone:847-934-8475
Mailing Address - Fax:
Practice Address - Street 1:807 DAVIS ST UNIT 605
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4820
Practice Address - Country:US
Practice Address - Phone:847-934-8475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060004613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL777420Medicare UPIN