Provider Demographics
NPI:1942379821
Name:HAVILAND, MARK WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:HAVILAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 LONG POINT RD
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-1072
Mailing Address - Country:US
Mailing Address - Phone:410-822-4613
Mailing Address - Fax:410-822-6534
Practice Address - Street 1:416 N 6TH ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-1356
Practice Address - Country:US
Practice Address - Phone:410-822-4613
Practice Address - Fax:410-822-6534
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216538Medicare ID - Type Unspecified