Provider Demographics
NPI:1861537425
Name:KETCHAM, JULIA (SLP)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8442 CERCO CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5713
Mailing Address - Country:US
Mailing Address - Phone:260-485-4672
Mailing Address - Fax:
Practice Address - Street 1:3320 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1918
Practice Address - Country:US
Practice Address - Phone:260-483-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22000296A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000265744OtherBLUE CROSS BLUE SHIELD