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General NPI Number Information
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NPI Number | 1699968453
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Entity Type | Individual
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Provider Name | ETHEL WIEST HETRICK PH.D.
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Gender | Female
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Dates
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Enumeration Date | 08/23/2007
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Last Update Date | 06/24/2014
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Provider Practice Location Address
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Address Line | 412 HIGHWAY 90 SUITE 10
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City | BAY SAINT LOUIS
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State | MS
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Zip | 39520-3534
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Country | US
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Telephone | 228-467-2424
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Fax | 228-467-5757
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Provider Business Mailing Address
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Address Line | 412 HIGHWAY 90 SUITE 10
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City | BAY SAINT LOUIS
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State | MS
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Zip | 39520-3534
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Country | US
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Telephone | 228-467-2424
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Fax | 228-467-5757
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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 | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 45 740
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 45 740
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License Number State | MS
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