MEDICARE: THE HAVEN COLLECTIVE, INC.

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	:	1376198788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HAVEN COLLECTIVE, INC.

Provider Business Mailing Address
First Line	:	9165 OTIS AVE STE 230
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46216-2321
Country	:	US
Telephone Number	:	317-509-5727
Fax Number	:

Provider Business Practice Location Address
First Line	:	9165 OTIS AVE STE 230
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46216-2321
Country	:	US
Telephone Number	:	317-509-5727
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. KISHA PARKER
Credential	:	M.A., LMFT
Telephone Number	:	317-509-5727

Provider Enumeration Date	:	08/03/2019
Last Update Date	:	08/03/2019

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