Healthcare Provider Details

I. General information

NPI: 1154861086
Provider Name (Legal Business Name): HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 CORDOVA ST STE 102
ANCHORAGE AK
99501-3783
US

IV. Provider business mailing address

7212 OYSTER LN
WILMINGTON NC
28411-7132
US

V. Phone/Fax

Practice location:
  • Phone: 910-399-3927
  • Fax: 855-774-1303
Mailing address:
  • Phone: 910-399-3927
  • Fax: 910-399-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number118712
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number118712
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number118712
License Number StateAK

VIII. Authorized Official

Name: DWIGHT HOWARD LYSNE
Title or Position: DIRECTOR
Credential: MD, MDIV
Phone: 910-399-3927