Healthcare Provider Details

I. General information

NPI: 1225174220
Provider Name (Legal Business Name): TIMOTHY USHER KETTERSON JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 SW 91ST TER SUITE A
GAINESVILLE FL
32608-8149
US

IV. Provider business mailing address

4965 SW 91ST TER SUITE A
GAINESVILLE FL
32608-8149
US

V. Phone/Fax

Practice location:
  • Phone: 352-337-0551
  • Fax: 352-374-2166
Mailing address:
  • Phone: 352-337-0551
  • Fax: 352-374-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY7453
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: