Provider Demographics
NPI:1720535883
Name:HETZLER, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:HETZLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHARING CROSS
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3905
Mailing Address - Country:US
Mailing Address - Phone:585-880-7197
Mailing Address - Fax:
Practice Address - Street 1:4901 LAC DE VILLE BLVD BLDG D
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5647
Practice Address - Country:US
Practice Address - Phone:585-341-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist