Provider Demographics
NPI:1447642236
Name:HAVENS, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:HAVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 STERLING RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-6124
Mailing Address - Country:US
Mailing Address - Phone:540-293-4872
Mailing Address - Fax:
Practice Address - Street 1:3480 STERLING RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-6124
Practice Address - Country:US
Practice Address - Phone:540-293-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602980225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant