Provider Demographics
NPI:1699306233
Name:KETTER, KHADEJHA
Entity type:Individual
Prefix:
First Name:KHADEJHA
Middle Name:
Last Name:KETTER
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 1:950 UNDERHILL AVE APT 19C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2731
Mailing Address - Country:US
Mailing Address - Phone:646-281-6914
Mailing Address - Fax:
Practice Address - Street 1:950 UNDERHILL AVE APT 19C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2731
Practice Address - Country:US
Practice Address - Phone:646-281-6914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1383458201106E00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty