MEDICARE: KETTELY ZIDOR

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699240481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETTELY ZIDOR

Provider Business Mailing Address
First Line	:	6841 HENDRY DR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7468
Country	:	US
Telephone Number	:	561-577-9404
Fax Number	:

Provider Business Practice Location Address
First Line	:	6841 HENDRY DR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7468
Country	:	US
Telephone Number	:	561-577-9404
Fax Number	:

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

Provider Enumeration Date	:	10/08/2018
Last Update Date	:	10/08/2018

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Directions to “ KETTELY ZIDOR ” Practice Location

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