Provider Demographics
NPI:1528193562
Name:HAVRILLA, ALFRED EDGAR (OTR)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:EDGAR
Last Name:HAVRILLA
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 ALDA DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-8702
Mailing Address - Country:US
Mailing Address - Phone:845-417-7224
Mailing Address - Fax:
Practice Address - Street 1:145 ALDA DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-8702
Practice Address - Country:US
Practice Address - Phone:845-382-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0031731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist