Provider Demographics
NPI:1831813104
Name:SIDELL, HAVEN
Entity type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:SIDELL
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 1:1628 E DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3810
Mailing Address - Country:US
Mailing Address - Phone:937-365-7455
Mailing Address - Fax:937-600-6071
Practice Address - Street 1:1628 E DOROTHY LN
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3810
Practice Address - Country:US
Practice Address - Phone:937-365-7455
Practice Address - Fax:937-600-6071
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-22-236356106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician