Provider Demographics
NPI:1063395325
Name:KETTWIG, TANNER WADE
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:WADE
Last Name:KETTWIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 S DISCOVERY BAY DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0397
Mailing Address - Country:US
Mailing Address - Phone:605-467-9129
Mailing Address - Fax:
Practice Address - Street 1:4040 S DISCOVERY BAY DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-0397
Practice Address - Country:US
Practice Address - Phone:605-467-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health