Provider Demographics
NPI:1669710737
Name:HAVEN PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:HAVEN PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LEERSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:218-885-1282
Mailing Address - Street 1:832 1ST ST STE 140
Mailing Address - Street 2:
Mailing Address - City:NASHWAUK
Mailing Address - State:MN
Mailing Address - Zip Code:55769-1245
Mailing Address - Country:US
Mailing Address - Phone:218-885-1282
Mailing Address - Fax:218-885-1471
Practice Address - Street 1:832 1ST ST STE 140
Practice Address - Street 2:
Practice Address - City:NASHWAUK
Practice Address - State:MN
Practice Address - Zip Code:55769-1245
Practice Address - Country:US
Practice Address - Phone:218-885-1282
Practice Address - Fax:218-885-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7201261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy