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General NPI Number Information
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NPI Number | 1962535419
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Entity Type | Individual
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Provider Name | LARRY KENNETH HETRICK JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 606 WILSON AVENUE
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City | NOVATO
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State | CA
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Zip | 94947-3817
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Country | US
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Telephone | 415-567-0321
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Fax | 415-647-0321
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Provider Business Mailing Address
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Address Line | P.O. BOX 14880
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City | SAN FRANCISCO
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State | CA
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Zip | 94114-0880
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Country | US
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Telephone | 415-567-0321
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Fax | 415-895-5548
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | G078733
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License Number State | CA
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