MEDICARE: MR. DESMOND E KETTER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10952	OK

General Provider Information

NPI Number	:	1194296210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DESMOND E KETTER LPC

Provider Business Mailing Address
First Line	:	3108 S HEMLOCK CT
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7602
Country	:	US
Telephone Number	:	918-645-6064
Fax Number	:

Provider Business Practice Location Address
First Line	:	5840 S MEMORIAL DR STE 330
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9060
Country	:	US
Telephone Number	:	918-200-9830
Fax Number	:	918-601-8103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	06/09/2025

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