Provider Demographics
NPI:1811359557
Name:KETTELHUT, JANET
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:KETTELHUT
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 1:921 ANITA CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4712
Mailing Address - Country:US
Mailing Address - Phone:925-284-1811
Mailing Address - Fax:
Practice Address - Street 1:1415 OAKLAND BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4386
Practice Address - Country:US
Practice Address - Phone:925-822-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT12719106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist