1225478167 NPI number — CHARLES WILLIAM KETCHEL LCSW-R

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225478167 NPI number — CHARLES WILLIAM KETCHEL LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHEL
Provider First Name:
CHARLES
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW-R
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KETCHEL
Provider Other First Name:
CHUCK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225478167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 FOREST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FABER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22938-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-758-2220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 FOREST LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FABER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22938-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-758-2220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2013

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: 1041C0700X , with the licence number:  904011232 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: R031920 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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