Provider Demographics
NPI:1013270735
Name:HAUSAM, DARYL (MA, LAT)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:HAUSAM
Suffix:
Gender:M
Credentials:MA, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 SUNFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4608
Mailing Address - Country:US
Mailing Address - Phone:254-291-6692
Mailing Address - Fax:
Practice Address - Street 1:4501 SUNFLOWER DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4608
Practice Address - Country:US
Practice Address - Phone:254-291-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT17372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer