Basic Information
| Provider Information | |||||||||
| NPI: | 1528275385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAVENS | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | DARLINGTON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 KENNEBEC RD | ||||||||
| Address2: | |||||||||
| City: | HAMPDEN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044441341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078622349 | ||||||||
| FaxNumber: | 2079903896 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079903896 | ||||||||
| FaxNumber: | 2079903896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC6946 | ME | X | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X | D198 | ME | X | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 002160 | 01 | ME | ANTHEM BCBS | OTHER |