Provider Demographics
NPI:1598390569
Name:HETTERMANN, ANNA J (LPC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:J
Last Name:HETTERMANN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 80TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4995
Mailing Address - Country:US
Mailing Address - Phone:262-806-1467
Mailing Address - Fax:262-661-7702
Practice Address - Street 1:4003 80TH ST STE 101
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4995
Practice Address - Country:US
Practice Address - Phone:262-806-1467
Practice Address - Fax:262-661-7702
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7717-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1598390569Medicaid