Provider Demographics
NPI:1285085597
Name:KETCHUM, CARLY (LMFT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CORTE VIDRIOSA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7009
Mailing Address - Country:US
Mailing Address - Phone:949-391-1812
Mailing Address - Fax:
Practice Address - Street 1:30200 RANCHO VIEJO RD STE D
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1560
Practice Address - Country:US
Practice Address - Phone:949-391-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist