Basic Information
| Provider Information | |||||||||
| NPI: | 1770605131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETCHUM | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 FISHER AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172320987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 FORDHAM RD | ||||||||
| Address2: | |||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021343006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177839676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.