1164864302 NPI number — HAVEN YOUTH AND FAMILY SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164864302 NPI number — HAVEN YOUTH AND FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVEN YOUTH AND FAMILY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164864302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANNAHON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60410-0613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-521-1889
Provider Business Mailing Address Fax Number:
815-521-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 GREEN BAY RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WILMETTE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60091-2597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-251-6630
Provider Business Practice Location Address Fax Number:
815-521-1889
Provider Enumeration Date:
07/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CHARLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
847-251-6630

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  149013375 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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