Basic Information
| Provider Information | |||||||||
| NPI: | 1083900583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVERTAPE | ||||||||
| FirstName: | LAINEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 PRAIRIE HEIGHTS DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088486628 | ||||||||
| FaxNumber: | 6088486629 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 PRAIRIE HEIGHTS DRIVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088486628 | ||||||||
| FaxNumber: | 6088486629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1177124 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05010306A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11771-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.