Provider Demographics
NPI:1326313396
Name:HETTER, JOAN (PTA)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:HETTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 TRYST LN
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1900
Mailing Address - Country:US
Mailing Address - Phone:919-830-5452
Mailing Address - Fax:
Practice Address - Street 1:5705 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5318
Practice Address - Country:US
Practice Address - Phone:919-434-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3615225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant