Provider Demographics
NPI:1093061046
Name:HAVERHALS, LEAH L (PT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:L
Last Name:HAVERHALS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HIGHWAY 65 S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1899
Mailing Address - Country:US
Mailing Address - Phone:320-225-3356
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-225-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016387225100000X
MN10602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01094077OtherRR MEDICARE