Healthcare Provider Details

I. General information

NPI: 1295936128
Provider Name (Legal Business Name): KAYLEEN HETRICK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 N KNIK ST
WASILLA AK
99654-7049
US

IV. Provider business mailing address

491 N KNIK ST
WASILLA AK
99654-7049
US

V. Phone/Fax

Practice location:
  • Phone: 907-232-9501
  • Fax: 907-376-9507
Mailing address:
  • Phone: 907-232-9501
  • Fax: 907-376-9507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number92
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: