Provider Demographics
NPI:1528456001
Name:HETRICK, LUANNE
Entity type:Individual
Prefix:
First Name:LUANNE
Middle Name:
Last Name:HETRICK
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 1:119 S ARTHURS CT
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-4131
Mailing Address - Country:US
Mailing Address - Phone:912-674-0883
Mailing Address - Fax:
Practice Address - Street 1:96 LAKESHORE DR STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3858
Practice Address - Country:US
Practice Address - Phone:912-510-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009260225700000X
FLMA72015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist