Healthcare Provider Details

I. General information

NPI: 1033028428
Provider Name (Legal Business Name): SCOTT MASTERS HETHERWICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 CORONA DR
LAFAYETTE LA
70503-4726
US

IV. Provider business mailing address

409 CORONA DR
LAFAYETTE LA
70503-4726
US

V. Phone/Fax

Practice location:
  • Phone: 337-257-6242
  • Fax:
Mailing address:
  • Phone: 337-257-6242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number50293
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: