Provider Demographics
NPI:1417185869
Name:HAVRON, COREEN KELLY (PT)
Entity Type:Individual
Prefix:
First Name:COREEN
Middle Name:KELLY
Last Name:HAVRON
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 1:9011 OLD CHARLOTTE PIKE
Mailing Address - Street 2:
Mailing Address - City:PEGRAM
Mailing Address - State:TN
Mailing Address - Zip Code:37143-9422
Mailing Address - Country:US
Mailing Address - Phone:615-216-5540
Mailing Address - Fax:
Practice Address - Street 1:9011 OLD CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:PEGRAM
Practice Address - State:TN
Practice Address - Zip Code:37143-9422
Practice Address - Country:US
Practice Address - Phone:615-216-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist