Provider Demographics
NPI:1912764341
Name:DEHAVEN, NIKOLAI
Entity Type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11714 STEARNS ST APT 6
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-3805
Mailing Address - Country:US
Mailing Address - Phone:913-735-4383
Mailing Address - Fax:
Practice Address - Street 1:11714 STEARNS ST APT 6
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-3805
Practice Address - Country:US
Practice Address - Phone:913-735-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04464101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty