Provider Demographics
NPI:1780220038
Name:GIRMENDONK, HAVEN
Entity Type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:GIRMENDONK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 OFFICE COURT DR STE 706
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4958
Mailing Address - Country:US
Mailing Address - Phone:505-316-0458
Mailing Address - Fax:
Practice Address - Street 1:4001 OFFICE COURT DR STE 706
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4958
Practice Address - Country:US
Practice Address - Phone:505-395-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM512214479103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst