Provider Demographics
NPI:1134308711
Name:HAVEN, CAROLYN M (P T)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:HAVEN
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 31ST AVE SW
Mailing Address - Street 2:PHYSICAL THERAPY DEPT
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 31ST AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3723
Practice Address - Country:US
Practice Address - Phone:509-241-7316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB32453Medicare PIN