Basic Information
| Provider Information | |||||||||
| NPI: | 1396012837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHS BEHAVIORAL MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | ST CATHERINE'S HALL, ROOM 102 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028544069 | ||||||||
| FaxNumber: | 2028547825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1053 BUCHANAN ST NE | ||||||||
| Address2: | SUITE 055 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022697626 | ||||||||
| FaxNumber: | 2022697616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2011 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HABERKERN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2028544255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | HFD01-0212 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 282N00000X | HFD01-0112 | DC | N | Hospitals | General Acute Care Hospital | 2084A0401X | HFD01-0212 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005145400 | 05 | MD | MEDICAID | 09810714 | 05 | VA | MEDICAID | 029833400 | 05 | DC | MEDICAID |