Basic Information
| Provider Information | |||||||||
| NPI: | 1083165633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYHAVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144458131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144458131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | DALTON | ||||||||
| AuthorizedOfficialFirstName: | NATALIE | ||||||||
| AuthorizedOfficialMiddleName: | DEANN | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6144458131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CDCA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 160921 | OH | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.