Provider Demographics
NPI:1164653283
Name:HETRICK, SUSAN (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HETRICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12120 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1254
Mailing Address - Country:US
Mailing Address - Phone:913-707-0870
Mailing Address - Fax:816-926-9180
Practice Address - Street 1:7611 STATE LINE RD
Practice Address - Street 2:SUITE 226
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-6801
Practice Address - Country:US
Practice Address - Phone:816-753-7071
Practice Address - Fax:816-926-9180
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional