Healthcare Provider Details

I. General information

NPI: 1124736491
Provider Name (Legal Business Name): HAVENS OF MINNESOTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 WOODDALE DR STE B
WOODBURY MN
55125-4442
US

IV. Provider business mailing address

2101 WOODDALE DR STE B
WOODBURY MN
55125-4442
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 TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: TEDD HERMAN
Title or Position: CEO
Credential:
Phone: 612-895-4605