Healthcare Provider Details

I. General information

NPI: 1467851824
Provider Name (Legal Business Name): ADAM KETCHERSIDE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 OFFICE CENTER AVE STE 100
SAINT LOUIS MO
63128-1392
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-7050
  • Fax: 314-729-0920
Mailing address:
  • Phone: 660-665-1962
  • Fax: 660-665-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2014007562
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: