Provider Demographics
NPI:1669936266
Name:KETOLA, MEGAN MICHELLE (PT,DPT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MICHELLE
Last Name:KETOLA
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W19399 KETOLA RD
Mailing Address - Street 2:
Mailing Address - City:GERMFASK
Mailing Address - State:MI
Mailing Address - Zip Code:49836-9249
Mailing Address - Country:US
Mailing Address - Phone:906-869-3284
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT S MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1822
Practice Address - Country:US
Practice Address - Phone:906-635-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist