Provider Demographics
NPI:1407074693
Name:HAVERSTOCK, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HAVERSTOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 S WALNUT RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2129
Mailing Address - Country:US
Mailing Address - Phone:219-229-0322
Mailing Address - Fax:708-479-2111
Practice Address - Street 1:344 S WALNUT RIDGE CT
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2129
Practice Address - Country:US
Practice Address - Phone:219-229-0322
Practice Address - Fax:708-479-2111
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012822225100000X, 2251P0200X
IN05007676A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist