Healthcare Provider Details

I. General information

NPI: 1487768495
Provider Name (Legal Business Name): DONNA L HAVENS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 GRAPEFIELD RD
BASTIAN VA
24314
US

IV. Provider business mailing address

12301 GRAPEFIELD RD
BASTIAN VA
24314
US

V. Phone/Fax

Practice location:
  • Phone: 276-688-4331
  • Fax: 276-688-4336
Mailing address:
  • Phone: 276-688-4331
  • Fax: 276-688-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001753
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: