Provider Demographics
NPI:1154861086
Name:HAVEN
Entity Type:Organization
Organization Name:HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:LYSNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MDIV
Authorized Official - Phone:910-399-3927
Mailing Address - Street 1:7212 OYSTER LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7132
Mailing Address - Country:US
Mailing Address - Phone:910-399-3927
Mailing Address - Fax:910-399-3928
Practice Address - Street 1:626 CORDOVA ST STE 102
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3783
Practice Address - Country:US
Practice Address - Phone:910-399-3927
Practice Address - Fax:855-774-1303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-25
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1187122084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty