Provider Demographics
NPI:1508869488
Name:HETHERINGTON, JOHN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W COTTONWOOD LN
Mailing Address - Street 2:STE 7
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-2552
Mailing Address - Country:US
Mailing Address - Phone:520-836-4618
Mailing Address - Fax:520-836-2650
Practice Address - Street 1:177 W COTTONWOOD LN
Practice Address - Street 2:STE 7
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-2552
Practice Address - Country:US
Practice Address - Phone:520-836-4618
Practice Address - Fax:520-836-2650
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
AZDA4090231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZOO76260OtherBLUE CROSS/BLUE SHIELD
WA133376OtherDEPT OF LABOR & INDUSTRIE
AZ1Z2179OtherHEALTHNET
AZ802117Medicaid
AZ1Z2179OtherHEALTHNET