Provider Demographics
NPI:1659682276
Name:HETTERICH, KIMBERLY ROSE (AUD, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:HETTERICH
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ROSE
Other - Last Name:VISNEFSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD, CCC-A
Mailing Address - Street 1:30 LONG BEACH DR
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-1835
Mailing Address - Country:US
Mailing Address - Phone:631-928-0188
Mailing Address - Fax:631-928-0185
Practice Address - Street 1:251 E OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2602
Practice Address - Country:US
Practice Address - Phone:631-928-0188
Practice Address - Fax:631-928-0185
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002295231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist