Provider Demographics
NPI:1083875660
Name:HAVEN BEHAVIORAL SERVICES OF PHOENIX, LLC
Entity Type:Organization
Organization Name:HAVEN BEHAVIORAL SERVICES OF PHOENIX, LLC
Other - Org Name:HAVEN SENIOR HORIZONS OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-9091
Mailing Address - Street 1:652 W IRIS DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3191
Mailing Address - Country:US
Mailing Address - Phone:615-250-9500
Mailing Address - Fax:615-250-9515
Practice Address - Street 1:16620 N 40TH ST
Practice Address - Street 2:SUITE I-1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3348
Practice Address - Country:US
Practice Address - Phone:602-923-5845
Practice Address - Fax:602-923-5846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3156261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ442893Medicaid
AZ442893Medicaid