Provider Demographics
NPI:1134138670
Name:ELLEN HAVERSTICK, PLLC
Entity Type:Organization
Organization Name:ELLEN HAVERSTICK, PLLC
Other - Org Name:ADVANCED PHYSICAL THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAVERSTICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:501-328-5878
Mailing Address - Street 1:1065 CLAYTON ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4329
Mailing Address - Country:US
Mailing Address - Phone:501-328-5878
Mailing Address - Fax:501-336-0119
Practice Address - Street 1:1065 CLAYTON ST
Practice Address - Street 2:SUITE 9
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4329
Practice Address - Country:US
Practice Address - Phone:501-328-5878
Practice Address - Fax:501-336-0119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5F408Medicare ID - Type UnspecifiedMEDICARE GROUP ID #