Provider Demographics
NPI:1164605432
Name:HETTINGA, LAURIE CAROL (DPT)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:CAROL
Last Name:HETTINGA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:LAURIE
Other - Middle Name:CAROL
Other - Last Name:MCCAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 SENECA ST
Mailing Address - Street 2:BOX 900
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2742
Mailing Address - Country:US
Mailing Address - Phone:206-341-0461
Mailing Address - Fax:206-223-6472
Practice Address - Street 1:948 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2010
Practice Address - Country:US
Practice Address - Phone:510-414-7191
Practice Address - Fax:510-526-2022
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5540HEOtherBLUE SHIELD #