Provider Demographics
NPI:1962596684
Name:KETCHMARK-RYAN, BETH ANN (PT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:KETCHMARK-RYAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21302 HIGH COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3203
Mailing Address - Country:US
Mailing Address - Phone:303-929-4707
Mailing Address - Fax:
Practice Address - Street 1:21302 HIGH COUNTRY DR
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-3203
Practice Address - Country:US
Practice Address - Phone:303-929-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014133225100000X
CA36765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist