Healthcare Provider Details

I. General information

NPI: 1801959499
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: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 651-734-9633
  • Fax: 651-734-9533
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 Number1011741-1-CDT
License Number StateMN

VIII. Authorized Official

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