Provider Demographics
NPI:1184055436
Name:HAVEN
Entity type:Organization
Organization Name:HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR & PASTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:LYSNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MDIV
Authorized Official - Phone:910-399-3927
Mailing Address - Street 1:20 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4924
Mailing Address - Country:US
Mailing Address - Phone:910-465-1935
Mailing Address - Fax:910-399-3928
Practice Address - Street 1:20 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4924
Practice Address - Country:US
Practice Address - Phone:910-399-3927
Practice Address - Fax:910-399-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003013782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty