Provider Demographics
NPI:1164472320
Name:HAVILAND, MONIQUE B (MSPT, CSCS, PES, CPI)
Entity Type:Individual
Prefix:MISS
First Name:MONIQUE
Middle Name:B
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:MSPT, CSCS, PES, CPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-0280
Mailing Address - Country:US
Mailing Address - Phone:775-783-7606
Mailing Address - Fax:775-783-7605
Practice Address - Street 1:1667 LUCERNE ST
Practice Address - Street 2:SUITE B
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4306
Practice Address - Country:US
Practice Address - Phone:775-783-7606
Practice Address - Fax:775-783-7605
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP24859Medicare UPIN
NVV100849Medicare ID - Type Unspecified