Provider Demographics
NPI:1730210675
Name:KETTYLE, CYNTHIA N (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:N
Last Name:KETTYLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 CHARLES RIVER ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-1003
Mailing Address - Country:US
Mailing Address - Phone:781-449-3799
Mailing Address - Fax:
Practice Address - Street 1:478 CHARLES RIVER ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-1003
Practice Address - Country:US
Practice Address - Phone:781-449-3799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA356952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry