Provider Demographics
NPI:1699968453
Name:HETRICK, ETHEL WIEST (PHD)
Entity type:Individual
Prefix:DR
First Name:ETHEL
Middle Name:WIEST
Last Name:HETRICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 HIGHWAY 90
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BAY SAINT 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 SAINT 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
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45 740103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02628066Medicaid