Basic Information
| Provider Information | |||||||||
| NPI: | 1114138567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HETHERINGTON | ||||||||
| FirstName: | KARIN | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON | ||||||||
| OtherFirstName: | KARIN | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3300 ALLEGHENY DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300664448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705655863 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2155 POST OAK TRITT RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300628620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705654044 | ||||||||
| FaxNumber: | 7705655653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT003583 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.