MEDICARE: MRS. MARIA KLETTE-KETCHUM MSW, LCSW, ACSW,SAP

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	1041C0700X	Clinical Social Worker	1895	LA

General Provider Information

NPI Number	:	1447243159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIA KLETTE-KETCHUM MSW, LCSW, ACSW,SAP

Provider Business Mailing Address
First Line	:	76230 HIGHWAY 1083
Second Line	:
City	:	COVINGTON
State	:	LA
Zip	:	70435-4050
Country	:	US
Telephone Number	:	985-624-2266
Fax Number	:	985-898-0945

Provider Business Practice Location Address
First Line	:	1350 PARK DR
Second Line	:	STE A
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3205
Country	:	US
Telephone Number	:	985-624-2266
Fax Number	:	985-898-0945

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

Provider Enumeration Date	:	08/27/2005
Last Update Date	:	07/27/2018

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