Provider Demographics
NPI:1043084163
Name:HABERSTROH, PARKER P
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:P
Last Name:HABERSTROH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 CHURCH RD W STE 112
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7154
Practice Address - Country:US
Practice Address - Phone:662-548-3650
Practice Address - Fax:662-654-8029
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist