Provider Demographics
NPI:1932641974
Name:HETRICK, KATHLEEN TERESA (DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:TERESA
Last Name:HETRICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24010 THE CLEARING DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9697
Mailing Address - Country:US
Mailing Address - Phone:434-363-5602
Mailing Address - Fax:
Practice Address - Street 1:17101 SNOWMOBILE LN STE 202
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7043
Practice Address - Country:US
Practice Address - Phone:907-694-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK113229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist