Provider Demographics
NPI:1386303808
Name:DEHAVEN, EMILY (PTA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8543 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-4022
Mailing Address - Country:US
Mailing Address - Phone:304-229-1010
Mailing Address - Fax:304-229-5151
Practice Address - Street 1:8543 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-4022
Practice Address - Country:US
Practice Address - Phone:304-229-1010
Practice Address - Fax:304-229-5151
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA002126225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPTA002126OtherPTA LICENSE