Healthcare Provider Details

I. General information

NPI: 1902281785
Provider Name (Legal Business Name): AMANDA NICOLE HAVENS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5385 HERITAGE DR
NASHPORT OH
43830
US

IV. Provider business mailing address

5385 HERITAGE DR
NASHPORT OH
43830-9717
US

V. Phone/Fax

Practice location:
  • Phone: 740-624-3792
  • Fax:
Mailing address:
  • Phone: 740-624-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number014155
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: