Provider Demographics
NPI:1083900583
Name:HAVERTAPE, LAINEY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LAINEY
Middle Name:
Last Name:HAVERTAPE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PRAIRIE HEIGHTS DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-848-6628
Mailing Address - Fax:608-848-6629
Practice Address - Street 1:411 PRAIRIE HEIGHTS DRIVE
Practice Address - Street 2:STE 101
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-848-6628
Practice Address - Fax:608-848-6629
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1177124225100000X
IN05010306A225100000X
WI11771-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist