Healthcare Provider Details

I. General information

NPI: 1992954663
Provider Name (Legal Business Name): TOMMY RACHEL KETCHESIDE MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N COLLEGE ST
HUNTSVILLE AR
72740-9672
US

IV. Provider business mailing address

1104 N COLLEGE ST
HUNTSVILLE AR
72740-9672
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-750-8967
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: