Healthcare Provider Details

I. General information

NPI: 1912647264
Provider Name (Legal Business Name): STEPHANIE KETTEL CDCA, CT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PARK AVE
IRONTON OH
45638-1502
US

IV. Provider business mailing address

PO BOX 108
IRONTON OH
45638-0108
US

V. Phone/Fax

Practice location:
  • Phone: 740-532-1613
  • Fax: 740-879-0599
Mailing address:
  • Phone: 740-532-1613
  • Fax: 740-879-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2405876-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184373
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: