Provider Demographics
NPI:1164812368
Name:HETRICK, PATRICIA (LMT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:HETRICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S ORCHARD ST
Mailing Address - Street 2:STE. A
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6722
Mailing Address - Country:US
Mailing Address - Phone:208-383-1070
Mailing Address - Fax:208-383-3702
Practice Address - Street 1:2300 S ORCHARD ST
Practice Address - Street 2:STE. A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6722
Practice Address - Country:US
Practice Address - Phone:208-383-1070
Practice Address - Fax:208-383-3702
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-727225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist