Provider Demographics
NPI:1164735254
Name:HAVEN MINISTRIES, INC. @ AGAPE
Entity Type:Organization
Organization Name:HAVEN MINISTRIES, INC. @ AGAPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
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:910-803-1620
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:910-803-1620
Mailing Address - Fax:215-902-4882
Practice Address - Street 1:3725B WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4140
Practice Address - Country:US
Practice Address - Phone:910-803-1620
Practice Address - Fax:215-902-4882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN MINISTRIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003013782084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty