Provider Demographics
NPI:1104023969
Name:HETHERWICK, CHAD (MS, RDN)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:HETHERWICK
Suffix:
Gender:M
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10214
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0214
Mailing Address - Country:US
Mailing Address - Phone:928-772-8652
Mailing Address - Fax:928-772-8078
Practice Address - Street 1:8508 N PRAIRIE VW
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86315-9089
Practice Address - Country:US
Practice Address - Phone:928-772-8652
Practice Address - Fax:928-772-8078
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1004X, 133VN1005X, 133VN1006X
960912133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106848Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY