Provider Demographics
NPI:1396093233
Name:KETTLING, ANDREA UMBACH (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:UMBACH
Last Name:KETTLING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:UMBACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1515 MOCKINGBIRD LN STE 580
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3236
Mailing Address - Country:US
Mailing Address - Phone:704-910-8381
Mailing Address - Fax:704-981-8282
Practice Address - Street 1:1515 MOCKINGBIRD LN STE 580
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3236
Practice Address - Country:US
Practice Address - Phone:704-910-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
NC4522103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral