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General NPI Number Information
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NPI Number | 1003430729
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Entity Type | Individual
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Provider Name | MATTHEW ANTHONY HETTENBACH PMHNP
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Gender | Male
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Dates
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Enumeration Date | 05/29/2020
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Last Update Date | 05/29/2020
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Provider Practice Location Address
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Address Line | 1244 WISCONSIN AVE
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City | RACINE
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State | WI
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Zip | 53403-1987
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Country | US
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Telephone | 262-687-2956
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Fax |
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Provider Business Mailing Address
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Address Line | 2019 SAINT CLAIR ST
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City | RACINE
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State | WI
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Zip | 53402-4763
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Country | US
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Telephone | 262-995-4662
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 10089
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License Number State | WI
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