Individual
DR. ETHEL WIEST HETRICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
412 HIGHWAY 90, SUITE 10, BAY SAINT LOUIS, MS 39520-3534
(228) 467-2424
(228) 467-5757
Mailing address
412 HIGHWAY 90, SUITE 10, BAY SAINT LOUIS, MS 39520-3534
(228) 467-2424
(228) 467-5757
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
45 740
MS
103T00000X
Psychologist
Primary
45 740
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02628066
—
MS
Enumeration date
08/23/2007
Last updated
06/24/2014
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