Provider Demographics
NPI:1720029655
Name:HAVERSTICK, ELLEN R (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:HAVERSTICK
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 1:367 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6319
Mailing Address - Country:US
Mailing Address - Phone:501-733-3969
Mailing Address - Fax:501-336-0119
Practice Address - Street 1:1065 CLAYTON ST
Practice Address - Street 2:SUITE 9
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4329
Practice Address - Country:US
Practice Address - Phone:501-328-5878
Practice Address - Fax:501-336-0119
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist