Provider Demographics
NPI:1225819592
Name:HETRICK, TRICIA MARIE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MARIE
Last Name:HETRICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 E ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3327
Mailing Address - Country:US
Mailing Address - Phone:480-276-4901
Mailing Address - Fax:
Practice Address - Street 1:9014 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8304
Practice Address - Country:US
Practice Address - Phone:480-276-4901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-08046T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health