MEDICARE: ONE HAVEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1144662941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE HAVEN

Provider Business Mailing Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-3554
Fax Number	:	801-355-3711

Provider Business Practice Location Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-3554
Fax Number	:	801-355-3711

Authorized Official
Title or Position	:	CEO/CLINICAL PSYCHOLOGIST
Name	:	DR. COLLEEN KUHN
Credential	:	PH.D.
Telephone Number	:	801-355-3554

Provider Enumeration Date	:	07/22/2013
Last Update Date	:	07/22/2013

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Directions to “ONE HAVEN ” Practice Location

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