Provider Demographics
NPI:1891254223
Name:HEAVEN, TOWAYN (LAC, LMT)
Entity Type:Individual
Prefix:MR
First Name:TOWAYN
Middle Name:
Last Name:HEAVEN
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7737 N EASTLAKE TER APT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1333
Mailing Address - Country:US
Mailing Address - Phone:872-223-8250
Mailing Address - Fax:
Practice Address - Street 1:2018 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-753-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001360171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist