Provider Demographics
NPI:1750880936
Name:HAVENS, KAYLA N
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:N
Last Name:HAVENS
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 1:14412 US HIGHWAY 23
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9337
Mailing Address - Country:US
Mailing Address - Phone:740-835-8283
Mailing Address - Fax:
Practice Address - Street 1:14412 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9337
Practice Address - Country:US
Practice Address - Phone:740-835-8283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165162101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1275589178Medicaid