Healthcare Provider Details

I. General information

NPI: 1164864302
Provider Name (Legal Business Name): HAVEN YOUTH AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 GREEN BAY RD SUITE 200
WILMETTE IL
60091-2597
US

IV. Provider business mailing address

PO BOX 613
CHANNAHON IL
60410-0613
US

V. Phone/Fax

Practice location:
  • Phone: 847-251-6630
  • Fax: 815-521-1889
Mailing address:
  • Phone: 815-521-1889
  • Fax: 815-521-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number149013375
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: CHARLEY SMITH
Title or Position: DIRECTOR
Credential: LCSW
Phone: 847-251-6630