Provider Demographics
NPI:1548540768
Name:KETCHUM, ADDIE J (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:J
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MOUNT CARMEL PL
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1714
Mailing Address - Country:US
Mailing Address - Phone:845-485-8901
Mailing Address - Fax:
Practice Address - Street 1:15 MOUNT CARMEL PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1714
Practice Address - Country:US
Practice Address - Phone:845-485-8901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0213051235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist