Provider Demographics
NPI:1396494456
Name:DEHAVEN, JOHN ROBERT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 E SANTA FE ST LOT 309
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-1546
Mailing Address - Country:US
Mailing Address - Phone:785-342-6622
Mailing Address - Fax:
Practice Address - Street 1:101 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-4416
Practice Address - Country:US
Practice Address - Phone:913-393-3828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS52591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical