Provider Demographics
NPI:1083193759
Name:HAVEN, BEAU (PT, DPT)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:HAVEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BEAU
Other - Middle Name:HAVEN
Other - Last Name:GRONERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:379 LANDER DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-1308
Mailing Address - Country:US
Mailing Address - Phone:702-701-3140
Mailing Address - Fax:
Practice Address - Street 1:2904 W HORIZON RIDGE PKWY STE 121
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5016
Practice Address - Country:US
Practice Address - Phone:702-897-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist