Provider Demographics
NPI:1487136271
Name:HAVERKAMP, AMY SUE (OTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:HAVERKAMP
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:HAVERKAMP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTA
Mailing Address - Street 1:2774 COUNTY ROAD 306
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-6760
Mailing Address - Country:US
Mailing Address - Phone:940-284-1424
Mailing Address - Fax:
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:TX
Practice Address - Zip Code:76233-5106
Practice Address - Country:US
Practice Address - Phone:940-284-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205004224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant