Healthcare Provider Details

I. General information

NPI: 1205439569
Provider Name (Legal Business Name): HAVEN CHEMICAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 9TH AVE
ST PAUL PARK MN
55071-1436
US

IV. Provider business mailing address

2042 WOODDALE DR STE 220
WOODBURY MN
55125-4421
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYNN FRAZERJOHN
Title or Position: ADMINISTRATOR
Credential:
Phone: 651-734-9633