Provider Demographics
NPI:1770159105
Name:HAVEN DETOX MA
Entity type:Organization
Organization Name:HAVEN DETOX MA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-552-3180
Mailing Address - Street 1:1369 GRAFTON ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-2737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1369 GRAFTON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-2737
Practice Address - Country:US
Practice Address - Phone:508-552-3180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility