Provider Demographics
NPI:1285365940
Name:KETCHMARK, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:KETCHMARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1246
Mailing Address - Country:US
Mailing Address - Phone:619-777-3758
Mailing Address - Fax:
Practice Address - Street 1:8200 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2528
Practice Address - Country:US
Practice Address - Phone:708-850-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist