MEDICARE: HAVEN CHEMICAL HEALTH SYSTEMS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1024597-1-CDT	MN

General Provider Information

NPI Number	:	1952464547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN CHEMICAL HEALTH SYSTEMS, LLC

Provider Business Mailing Address
First Line	:	2042 WOODDALE DR
Second Line	:	SUITE 220
City	:	WOODBURY
State	:	MN
Zip	:	55125-2981
Country	:	US
Telephone Number	:	651-734-9633
Fax Number	:	651-734-9533

Provider Business Practice Location Address
First Line	:	21077 PENROSE AVE N
Second Line	:
City	:	SCANDIA
State	:	MN
Zip	:	55073-9710
Country	:	US
Telephone Number	:	651-433-5839
Fax Number	:	651-433-5921

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT HAVEN
Credential	:
Telephone Number	:	651-734-9633

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/22/2020

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