MEDICARE: MR. ALAN P KETTERLING MA, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	15683	AZ
2	106H00000X	Marriage & Family Therapist	LAMFT-10584	AZ

General Provider Information

NPI Number	:	1306333133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALAN P KETTERLING MA, LMFT

Provider Business Mailing Address
First Line	:	18450 W BROOKWOOD DR
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85338-6476
Country	:	US
Telephone Number	:	623-377-4737
Fax Number	:

Provider Business Practice Location Address
First Line	:	5902 W CACTUS RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1710
Country	:	US
Telephone Number	:	623-377-4737
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	09/29/2023

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