Provider Demographics
NPI:1770995011
Name:HAVEN BEHAVIORAL
Entity type:Organization
Organization Name:HAVEN BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-640-5445
Mailing Address - Street 1:9420 S AVERS AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2007
Mailing Address - Country:US
Mailing Address - Phone:708-285-0578
Mailing Address - Fax:
Practice Address - Street 1:1330 QUAIL LAKE LOOP
Practice Address - Street 2:SUITE 240
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4651
Practice Address - Country:US
Practice Address - Phone:719-640-5445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0-14-5932103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty