Healthcare Provider Details

I. General information

NPI: 1750081832
Provider Name (Legal Business Name): TRISTAN M KETTEL CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 E STEVENS ST
NEWARK OH
43055-5900
US

IV. Provider business mailing address

62 E STEVENS ST
NEWARK OH
43055-5900
US

V. Phone/Fax

Practice location:
  • Phone: 740-366-7303
  • Fax:
Mailing address:
  • Phone: 740-366-7303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.183783
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: