MEDICARE: HAVEN MIND BODY COLLECTIVE, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1184477507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN MIND BODY COLLECTIVE, LLC

Provider Business Mailing Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	360-703-6499
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	360-703-6499
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED COUNSELOR
Name	:	AMANDA RENEE HART
Credential	:	CC
Telephone Number	:	360-562-5509

Provider Enumeration Date	:	04/08/2024
Last Update Date	:	04/08/2024

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