Provider Demographics
NPI:1215060520
Name:KETTINGER, KIMBERLY SUE (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:KETTINGER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:HALTERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3828 SARRIA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1626
Practice Address - Country:US
Practice Address - Phone:863-318-1315
Practice Address - Fax:863-326-9432
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant