Provider Demographics
NPI:1447017306
Name:KETCHO, BRIANNA (PTA)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:KETCHO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1933
Mailing Address - Country:US
Mailing Address - Phone:570-905-5846
Mailing Address - Fax:
Practice Address - Street 1:137 BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:PA
Practice Address - Zip Code:18641-1933
Practice Address - Country:US
Practice Address - Phone:570-905-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE013289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant