Provider Demographics
NPI:1891237228
Name:HAVIKEN, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:HAVIKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 W PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8459
Mailing Address - Country:US
Mailing Address - Phone:208-719-7158
Mailing Address - Fax:
Practice Address - Street 1:827 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8459
Practice Address - Country:US
Practice Address - Phone:208-719-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-42848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty