Provider Demographics
NPI:1588126106
Name:KETCHUM, ALISHA DAWN
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:DAWN
Last Name:KETCHUM
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 1:2 N BUCK RD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5888
Mailing Address - Country:US
Mailing Address - Phone:918-302-7792
Mailing Address - Fax:
Practice Address - Street 1:2 N BUCK RD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5888
Practice Address - Country:US
Practice Address - Phone:918-302-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator