Basic Information
| Provider Information | |||||||||
| NPI: | 1811659030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTLEWELL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MOT, OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDOWELL | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MOT, OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 VIRGINIA DRIVE | ||||||||
| Address2: | |||||||||
| City: | STEPHENS CITY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406641200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 BELLVIEW AVENUE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405420200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.