=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558252718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ANN HETRICK MA, COUNSELING
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2025
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1555 FORDING ISLAND RD STE C1
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-815-6789
-----------------------------------------------------
Fax | 843-815-6788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 SHINEY LEAF CT
-----------------------------------------------------
City | BEAUFORT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29907-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-263-7364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 10305
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------