Provider Demographics
NPI:1003579384
Name:KETCHUM, KATELYNNE (RBT)
Entity type:Individual
Prefix:
First Name:KATELYNNE
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3480 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4032
Practice Address - Country:US
Practice Address - Phone:928-438-9985
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ253J00000X, 385HR2055X
AZRBT-21-188875106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child