Provider Demographics
NPI:1093037699
Name:HAVLICEK, ANNETTE M (CMT)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:M
Last Name:HAVLICEK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR TOWNSHIP
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5835
Mailing Address - Country:US
Mailing Address - Phone:651-400-0884
Mailing Address - Fax:
Practice Address - Street 1:1756 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR TOWNSHIP
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-400-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MN00006347225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist