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General NPI Number Information
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NPI Number | 1659682276
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Entity Type | Individual
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Provider Name | KIMBERLY ROSE HETTERICH AU.D., CCC-A
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Gender | Female
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Dates
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Enumeration Date | 06/29/2010
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Last Update Date | 07/12/2011
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Provider Practice Location Address
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Address Line | 251 E OAKLAND AVE
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2602
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Country | US
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Telephone | 631-928-0188
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Fax | 631-928-0185
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Provider Business Mailing Address
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Address Line | 30 LONG BEACH DR
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City | SOUND BEACH
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State | NY
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Zip | 11789-1835
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Country | US
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Telephone | 631-928-0188
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Fax | 631-928-0185
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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 | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 002295
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License Number State | NY
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