Basic Information
| Provider Information | |||||||||
| NPI: | 1912105222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETCHUM | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR.L, CNMI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1170 ERBS QUARRY RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175439767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175379131 | ||||||||
| FaxNumber: | 7178034038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2007 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC004445L | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1019660090008 | 05 | PA | MEDICAID |