Provider Demographics
NPI:1215300819
Name:THE HAVEN'S OUTPATIENT CLINIC
Entity type:Organization
Organization Name:THE HAVEN'S OUTPATIENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-623-4590
Mailing Address - Street 1:1107 E ADELAIDE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2651
Mailing Address - Country:US
Mailing Address - Phone:520-623-4590
Mailing Address - Fax:520-207-3531
Practice Address - Street 1:2601 N CAMPBELL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2651
Practice Address - Country:US
Practice Address - Phone:520-623-4590
Practice Address - Fax:520-623-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7623324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ077397Medicaid