Provider Demographics
NPI:1861781791
Name:KETNER, AMY LYNN (MA, LCMHC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:KETNER
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96860
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28296-6860
Mailing Address - Country:US
Mailing Address - Phone:910-410-7083
Mailing Address - Fax:
Practice Address - Street 1:600 NEW WAVERLY PL STE 203
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7404
Practice Address - Country:US
Practice Address - Phone:919-410-7083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11489101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
NC1861781791Medicaid