Basic Information
| Provider Information | |||||||||
| NPI: | 1164472320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVILAND | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | MSPT, CSCS, PES, CPI | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | MINDEN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894230280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757837606 | ||||||||
| FaxNumber: | 7757837605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1667 LUCERNE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MINDEN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894234306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757837606 | ||||||||
| FaxNumber: | 7757837605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1784 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.