Provider Demographics
NPI:1194092130
Name:HEAVENSFIELD GROUP, LLC
Entity type:Organization
Organization Name:HEAVENSFIELD GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COSETTE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LSWAIC
Authorized Official - Phone:425-417-0406
Mailing Address - Street 1:1001 290TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-7403
Mailing Address - Country:US
Mailing Address - Phone:425-222-3706
Mailing Address - Fax:888-788-3419
Practice Address - Street 1:1001 290TH AVE SE
Practice Address - Street 2:
Practice Address - City:FALL CITY
Practice Address - State:WA
Practice Address - Zip Code:98024-7403
Practice Address - Country:US
Practice Address - Phone:425-222-3706
Practice Address - Fax:888-788-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003472101YM0800X
WASC601060471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty