Provider Demographics
NPI:1083103097
Name:HAVEN, DREW RHYS (LMT)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:RHYS
Last Name:HAVEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12843 SE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4588
Mailing Address - Country:US
Mailing Address - Phone:704-608-7777
Mailing Address - Fax:
Practice Address - Street 1:8122 SE TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1768
Practice Address - Country:US
Practice Address - Phone:704-608-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist