Basic Information
| Provider Information | |||||||||
| NPI: | 1649647660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETRICK | ||||||||
| FirstName: | COLLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6849 OLD DOMINION DR STE 330 | ||||||||
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| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6849 OLD DOMINION DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038489333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2015 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070021755 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.