Basic Information
| Provider Information | |||||||||
| NPI: | 1407074693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVERSTOCK | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 344 S WALNUT RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604232129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290322 | ||||||||
| FaxNumber: | 7084792111 | ||||||||
| Practice Location | |||||||||
| Address1: | 344 S WALNUT RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604232129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290322 | ||||||||
| FaxNumber: | 7084792111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070012822 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | 070012822 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225100000X | 05007676A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.