Provider Demographics
NPI:1194782920
Name:HETER, KRISTIN L
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:HETER
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 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-682-8840
Mailing Address - Fax:423-602-2028
Practice Address - Street 1:1424 HIGHWAY 17 N STE 2
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2507
Practice Address - Country:US
Practice Address - Phone:843-427-7132
Practice Address - Fax:843-427-7154
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32683225100000X
NCP14185225100000X
SC9372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ43382B704Medicare PIN