=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417437401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLISON HETRICK ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2018
-----------------------------------------------------
Last Update Date | 08/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 BIRCH ST
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-3418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-293-0865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6116
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26506-6116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-293-0865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT001097
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------