1336270578 NPI number — DR. VIRGINIA KAY KETTENBACH PT,PHD

Table of content: CAROLE SUSAN FIRESTONE-GILLIS M.A., M.F.T. (NPI 1740491356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336270578 NPI number — DR. VIRGINIA KAY KETTENBACH PT,PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTENBACH
Provider First Name:
VIRGINIA
Provider Middle Name:
KAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT,PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336270578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1123 CHATELET DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63135-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-8543
Provider Business Mailing Address Fax Number:
314-977-8513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3437 CAROLINE ST., ROOM 1030
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-8543
Provider Business Practice Location Address Fax Number:
314-977-8513
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  RO313 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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