Provider Demographics
NPI:1922130772
Name:HETRICK, KIMBERLY LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:HETRICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 KINGS DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-9301
Mailing Address - Country:US
Mailing Address - Phone:717-279-8486
Mailing Address - Fax:
Practice Address - Street 1:1020 N UNION ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-2158
Practice Address - Country:US
Practice Address - Phone:717-930-1271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE001662L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant