Healthcare Provider Details

I. General information

NPI: 1952464547
Provider Name (Legal Business Name): HAVEN CHEMICAL HEALTH SYSTEMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21077 PENROSE AVE N
SCANDIA MN
55073-9710
US

IV. Provider business mailing address

2042 WOODDALE DR SUITE 220
WOODBURY MN
55125-2981
US

V. Phone/Fax

Practice location:
  • Phone: 651-433-5839
  • Fax: 651-433-5921
Mailing address:
  • Phone: 651-734-9633
  • Fax: 651-734-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1024597-1-CDT
License Number StateMN

VIII. Authorized Official

Name: ROBERT HAVEN
Title or Position: PRESIDENT
Credential:
Phone: 651-734-9633