Provider Demographics
NPI:1417438003
Name:HAVARD, STEPHEN WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:HAVARD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0995
Mailing Address - Country:US
Mailing Address - Phone:870-310-1616
Mailing Address - Fax:
Practice Address - Street 1:406 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3226
Practice Address - Country:US
Practice Address - Phone:903-342-2310
Practice Address - Fax:903-342-6796
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2081360225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant