Provider Demographics
NPI:1942473780
Name:HAVEN HOUSE COMMUNITY SUPPORT CENTER OF PRICE COUNTY
Entity Type:Organization
Organization Name:HAVEN HOUSE COMMUNITY SUPPORT CENTER OF PRICE COUNTY
Other - Org Name:HAVEN HOUSE COMMUNITY SUPPORT CENTER OF PRICE CO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED CLINICAL SO
Authorized Official - Phone:715-339-6449
Mailing Address - Street 1:548 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555
Mailing Address - Country:US
Mailing Address - Phone:715-339-6449
Mailing Address - Fax:715-339-6450
Practice Address - Street 1:548 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555
Practice Address - Country:US
Practice Address - Phone:715-339-6449
Practice Address - Fax:715-339-6450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HOUSE COMMUNITY SUPPORT CENTER OF PRICE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-11
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI753145419251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43429400Medicaid