Provider Demographics
NPI:1972136810
Name:HAVEN, GREGORY JOHN (ABA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:HAVEN
Suffix:
Gender:M
Credentials:ABA
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:JOHN
Other - Last Name:HAVEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2091 BORDEAU RD
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-9627
Mailing Address - Country:US
Mailing Address - Phone:989-359-9194
Mailing Address - Fax:
Practice Address - Street 1:2737 DEEP RIVER ROAD
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658
Practice Address - Country:US
Practice Address - Phone:989-359-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI016548662OtherTRICARE