Provider Demographics
NPI:1215342514
Name:ETHEL W HETRICK PHD PLLC
Entity type:Organization
Organization Name:ETHEL W HETRICK PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-467-2424
Mailing Address - Street 1:412 HIGHWAY 90
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-3534
Mailing Address - Country:US
Mailing Address - Phone:228-467-2424
Mailing Address - Fax:228-467-5757
Practice Address - Street 1:412 HIGHWAY 90
Practice Address - Street 2:SUITE 10
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-3534
Practice Address - Country:US
Practice Address - Phone:228-467-2424
Practice Address - Fax:228-467-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45 740103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02628066Medicaid