MEDICARE: HAVEN BEHAVIORAL OUTPATIENT SERVICES OF COLORADO, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1477198067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN BEHAVIORAL OUTPATIENT SERVICES OF COLORADO, LLC

Provider Business Mailing Address
First Line	:	1330 QUAIL LAKE LOOP STE 200
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4651
Country	:	US
Telephone Number	:	719-540-2152
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 PRINTERS PKWY STE 120
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-6101
Country	:	US
Telephone Number	:	719-540-2160
Fax Number	:	719-540-2101

Authorized Official
Title or Position	:	OPERATIONS DIRECTOR
Name	:	SHERIE TERRANOVA
Credential	:
Telephone Number	:	719-540-2152

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	11/07/2019

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