Provider Demographics
NPI:1023079555
Name:DEHAVEN, ROBERT W (MS, NCC, LPC, DAPA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:MS, NCC, LPC, DAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 RAY RD
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-5119
Mailing Address - Country:US
Mailing Address - Phone:478-296-9394
Mailing Address - Fax:478-296-9394
Practice Address - Street 1:121 RAY RD
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-5119
Practice Address - Country:US
Practice Address - Phone:478-296-9394
Practice Address - Fax:478-296-9394
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003880101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11367944OtherCAQH