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General NPI Number Information
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NPI Number | 1770159105
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Entity Type | Organization
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Legal Business Name | HAVEN DETOX MA
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 1369 GRAFTON ST
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City | WORCESTER
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State | MA
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Zip | 01604-2737
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Country | US
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Telephone | 508-552-3180
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Fax |
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Provider Business Mailing Address
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Address Line | 1369 GRAFTON ST
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City | WORCESTER
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State | MA
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Zip | 01604-2737
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JOHN MARONEY
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Credential |
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Telephone | 508-552-3180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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