Provider Demographics
NPI:1992957625
Name:HAVRILESKO, DOUGLAS M
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:M
Last Name:HAVRILESKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-1260
Mailing Address - Country:US
Mailing Address - Phone:724-222-8549
Mailing Address - Fax:
Practice Address - Street 1:60 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:BETHEL PARK
Practice Address - State:PA
Practice Address - Zip Code:15102-1806
Practice Address - Country:US
Practice Address - Phone:421-831-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE001786L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant