Provider Demographics
NPI:1124639190
Name:WOODHAVEN WELLNESS LLC
Entity type:Organization
Organization Name:WOODHAVEN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATTISON-WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:763-478-7395
Mailing Address - Street 1:3000 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:HAMEL
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9597
Mailing Address - Country:US
Mailing Address - Phone:763-478-7395
Mailing Address - Fax:
Practice Address - Street 1:30 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1515
Practice Address - Country:US
Practice Address - Phone:763-478-7395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)