Provider Demographics
NPI:1144436775
Name:KETTER, CYNTHIA VIDA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:VIDA
Last Name:KETTER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618A PAINE ST
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-1042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 W. MASON ST.
Practice Address - Street 2:STE. 104
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-737-4135
Practice Address - Fax:920-490-9705
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist