Provider Demographics
NPI:1174214456
Name:HAMPTON, HAVEN
Entity type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:HAMPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23034 STATE HIGHWAY 110 N
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-7320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E FRONT ST STE 123
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8250
Practice Address - Country:US
Practice Address - Phone:903-531-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist