Provider Demographics
NPI:1285084517
Name:KETTAVONG COUNSELING, LLC
Entity type:Organization
Organization Name:KETTAVONG COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-803-9724
Mailing Address - Street 1:18 ONECO ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-3440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 ONECO ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3440
Practice Address - Country:US
Practice Address - Phone:860-822-3208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-17
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty