Provider Demographics
NPI:1093325979
Name:HETHERINGTON, SAMUEL TIMOTHY (DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:TIMOTHY
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6311
Mailing Address - Country:US
Mailing Address - Phone:208-463-0022
Mailing Address - Fax:208-463-0031
Practice Address - Street 1:2005 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6311
Practice Address - Country:US
Practice Address - Phone:208-463-0022
Practice Address - Fax:208-463-0031
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-6926OtherSTATE LICENSE