Provider Demographics
NPI:1700125036
Name:THE HAVEN GROUP
Entity type:Organization
Organization Name:THE HAVEN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER, THERAPIST, DOULA
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CD(DONA)
Authorized Official - Phone:773-304-6483
Mailing Address - Street 1:1350 W FULLERTON AVE
Mailing Address - Street 2:#305
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2198
Mailing Address - Country:US
Mailing Address - Phone:773-304-6483
Mailing Address - Fax:
Practice Address - Street 1:1350 W FULLERTON AVE
Practice Address - Street 2:#305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2198
Practice Address - Country:US
Practice Address - Phone:773-304-6483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007445101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty