Provider Demographics
NPI:1053859553
Name:HEAVEN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HEAVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BLUE HILLS AVE
Mailing Address - Street 2:APT B2
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1254
Mailing Address - Country:US
Mailing Address - Phone:860-242-0848
Mailing Address - Fax:
Practice Address - Street 1:601 BLUE HILLS AVE
Practice Address - Street 2:APT B2
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1254
Practice Address - Country:US
Practice Address - Phone:860-242-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)