Provider Demographics
NPI:1992912216
Name:HAVENS, MATT (MSW LCSW, MS PA-C)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HAVENS
Suffix:
Gender:M
Credentials:MSW LCSW, MS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6501
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:1300 N OAKLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3018
Practice Address - Country:US
Practice Address - Phone:417-326-7676
Practice Address - Fax:417-326-3939
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050290851041C0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical