=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952464547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVEN CHEMICAL HEALTH SYSTEMS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21077 PENROSE AVE N
-----------------------------------------------------
City | SCANDIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55073-9710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-433-5839
-----------------------------------------------------
Fax | 651-433-5921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2042 WOODDALE DR SUITE 220
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-734-9633
-----------------------------------------------------
Fax | 651-734-9533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT HAVEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-734-9633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1024597-1-CDT
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------