Provider Demographics
NPI:1447903315
Name:KETCH, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KETCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 COURT ST
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-2076
Mailing Address - Country:US
Mailing Address - Phone:207-329-0744
Mailing Address - Fax:
Practice Address - Street 1:44 PARK ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2140
Practice Address - Country:US
Practice Address - Phone:207-764-3721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESAS34882355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESAS3488Medicaid