Provider Demographics
NPI:1528384427
Name:HETTERICH, REBECCA (MPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HETTERICH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ROUTE 66 E
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:CT
Mailing Address - Zip Code:06237-1224
Mailing Address - Country:US
Mailing Address - Phone:860-228-0194
Mailing Address - Fax:860-228-2694
Practice Address - Street 1:106 ROUTE 66 E
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:CT
Practice Address - Zip Code:06237-1224
Practice Address - Country:US
Practice Address - Phone:860-228-0194
Practice Address - Fax:860-228-2694
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist