Provider Demographics
NPI:1992954663
Name:KETCHESIDE, TOMMY RACHEL (MHPP)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:RACHEL
Last Name:KETCHESIDE
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72740-9672
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-8967
Practice Address - Street 1:1104 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72740-9672
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-750-8967
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other