Provider Demographics
NPI:1518514454
Name:HETTICH, ASHLEY NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:HETTICH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W310S196 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-9340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 S MOUNTIN DR
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1498
Practice Address - Country:US
Practice Address - Phone:920-387-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist