Provider Demographics
NPI:1699252668
Name:HERNDON, HAVEN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:HERNDON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 E JOYCE BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3924
Mailing Address - Country:US
Mailing Address - Phone:479-521-7337
Mailing Address - Fax:479-521-7338
Practice Address - Street 1:2580 E JOYCE BLVD STE 12
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-521-7337
Practice Address - Fax:479-521-7338
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60936305225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AROT2018015OtherOT STATE MEDICAL LICENSE