Provider Demographics
NPI:1912643339
Name:KETCHAM, GRACE PROSPERI (PSYD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:PROSPERI
Last Name:KETCHAM
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:CHRISTINE
Other - Last Name:PROSPERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5402 ROUTE 113
Mailing Address - Street 2:
Mailing Address - City:THETFORD CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05075-8915
Mailing Address - Country:US
Mailing Address - Phone:636-368-6492
Mailing Address - Fax:
Practice Address - Street 1:2 BUCK RD STE J
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-2715
Practice Address - Country:US
Practice Address - Phone:603-865-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist