Provider Demographics
NPI:1962853085
Name:HETLAND, EMMYLOU ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:EMMYLOU
Middle Name:ROSE
Last Name:HETLAND
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 1:621 SCIENCE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1074
Mailing Address - Country:US
Mailing Address - Phone:608-265-3341
Mailing Address - Fax:623-551-5078
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-265-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist