Basic Information
| Provider Information | |||||||||
| NPI: | 1609933449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTNER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MANDLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3141 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3141 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1075 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.