Provider Demographics
NPI:1114053766
Name:HETHERINGTON, JOSHUA SMITH (MSMFT)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:SMITH
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:MSMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 W NORTH SHORE AVE
Mailing Address - Street 2:APT 1S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4664
Mailing Address - Country:US
Mailing Address - Phone:773-791-0469
Mailing Address - Fax:
Practice Address - Street 1:1770 W BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1849
Practice Address - Country:US
Practice Address - Phone:773-791-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003937101YP2500X
IL166-000557106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional