Provider Demographics
NPI:1750440442
Name:HAWORTH, DEBRA ELOISE (PT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ELOISE
Last Name:HAWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-2130
Mailing Address - Country:US
Mailing Address - Phone:765-497-1521
Mailing Address - Fax:765-497-1908
Practice Address - Street 1:127 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-2130
Practice Address - Country:US
Practice Address - Phone:765-497-1521
Practice Address - Fax:765-497-1908
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002133A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100086060Medicaid