Provider Demographics
NPI:1912238288
Name:HAVERKAMP, KRISTEN ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:HAVERKAMP
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:RAABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1504 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3100
Mailing Address - Country:US
Mailing Address - Phone:920-563-9357
Mailing Address - Fax:920-568-6545
Practice Address - Street 1:1504 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3100
Practice Address - Country:US
Practice Address - Phone:920-563-9357
Practice Address - Fax:920-568-6545
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004516225100000X
IL070017861225100000X
WI11846-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA004516OtherPHYSICAL THERAPY LICENSE NUMBER
IL070017861OtherPT LICENSE NUMBER
IAI18344021Medicare Oscar/Certification