Healthcare Provider Details

I. General information

NPI: 1003722141
Provider Name (Legal Business Name): ISAIAH SAMUEL HETEBRINK MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N HARBOR BLVD STE 600A
FULLERTON CA
92835-4119
US

IV. Provider business mailing address

2760 ASSOCIATED RD APT D14
FULLERTON CA
92835-2951
US

V. Phone/Fax

Practice location:
  • Phone: 714-248-5185
  • Fax:
Mailing address:
  • Phone: 559-904-6930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23434
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: