Healthcare Provider Details

I. General information

NPI: 1538550702
Provider Name (Legal Business Name): HAVEN BEHAVIORAL SERVICES OF ALBUQUERQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD. SE 4TH FLOOR
ALBUQUERQUE NM
87108-4763
US

IV. Provider business mailing address

3102 WEST END AVENUE SUITE 1000
NASHVILLE TN
37203-1324
US

V. Phone/Fax

Practice location:
  • Phone: 505-254-4500
  • Fax: 505-266-0838
Mailing address:
  • Phone: 615-393-8800
  • Fax: 615-393-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JANIE PICKLE
Title or Position: VP/COMPTROLLER
Credential:
Phone: 615-393-8809