Provider Demographics
NPI:1487101358
Name:KETCHAM, KEVIN JOHN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:KETCHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6623 ELLIS AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-3521
Mailing Address - Country:US
Mailing Address - Phone:360-333-4820
Mailing Address - Fax:
Practice Address - Street 1:6623 ELLIS AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-3521
Practice Address - Country:US
Practice Address - Phone:360-333-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst