Provider Demographics
NPI:1528498094
Name:HETRICK, LAURA (LISW-CP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HETRICK
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 AZALEA AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-8042
Mailing Address - Country:US
Mailing Address - Phone:843-798-3555
Mailing Address - Fax:
Practice Address - Street 1:214 FOX HUNT PL
Practice Address - Street 2:
Practice Address - City:GALIVANTS FERRY
Practice Address - State:SC
Practice Address - Zip Code:29544-8072
Practice Address - Country:US
Practice Address - Phone:843-798-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC168541041C0700X, 104100000X
OHI.2405539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical