Provider Demographics
NPI:1144768201
Name:HETHERINGTON, SKYE ROSE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SKYE
Middle Name:ROSE
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 EDWARDS PL
Mailing Address - Street 2:APT. 101
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1800
Mailing Address - Country:US
Mailing Address - Phone:208-891-8929
Mailing Address - Fax:
Practice Address - Street 1:11628 OLD BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7030
Practice Address - Country:US
Practice Address - Phone:314-596-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160258182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer