Provider Demographics
NPI:1174375927
Name:KETTERL, MELISSA ANN (LBSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KETTERL
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:MISSY
Other - Middle Name:ANN
Other - Last Name:LEKANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:P.O. BOX 190
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:ND
Mailing Address - Zip Code:58045-0190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 W. CALEDONIA AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:ND
Practice Address - Zip Code:58045-0190
Practice Address - Country:US
Practice Address - Phone:701-636-5220
Practice Address - Fax:701-636-5221
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1467934Medicaid