Provider Demographics
NPI:1912150400
Name:HAVEN, LINDA LEE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LEE
Last Name:HAVEN
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 1:2410 E FARRAND RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-9149
Mailing Address - Country:US
Mailing Address - Phone:810-686-8390
Mailing Address - Fax:
Practice Address - Street 1:2410 E FARRAND RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-9149
Practice Address - Country:US
Practice Address - Phone:810-686-8390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF250001791320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0339997Medicaid