Provider Demographics
NPI:1285117416
Name:KETTERING, LISA KIRKPATRICK (APC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KIRKPATRICK
Last Name:KETTERING
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BILLIES CV SE
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6894
Mailing Address - Country:US
Mailing Address - Phone:678-770-1280
Mailing Address - Fax:
Practice Address - Street 1:6548 HIGHWAY 92 STE 100
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-2572
Practice Address - Country:US
Practice Address - Phone:678-770-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health