Provider Demographics
NPI:1669810990
Name:HAVERPORTH, RACHAEL E (PT)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:E
Last Name:HAVERPORTH
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 1:2436 CHERRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7740
Mailing Address - Country:US
Mailing Address - Phone:575-439-9878
Mailing Address - Fax:575-439-9876
Practice Address - Street 1:1011 10TH ST
Practice Address - Street 2:A
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6425
Practice Address - Country:US
Practice Address - Phone:575-439-9878
Practice Address - Fax:575-439-9876
Is Sole Proprietor?:No
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4296OtherPHYSICAL THERAPY LICENSE