Provider Demographics
NPI:1528275385
Name:HAVENS, PHYLLIS DARLINGTON (RD, LCSW)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:DARLINGTON
Last Name:HAVENS
Suffix:
Gender:F
Credentials:RD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 KENNEBEC RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1341
Mailing Address - Country:US
Mailing Address - Phone:207-862-2349
Mailing Address - Fax:207-990-3896
Practice Address - Street 1:40 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6446
Practice Address - Country:US
Practice Address - Phone:207-990-3896
Practice Address - Fax:207-990-3896
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC69461041C0700X
MED198133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002160OtherANTHEM BCBS