Provider Demographics
NPI:1871623819
Name:HAVENS, GLEN H (MD PC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:H
Last Name:HAVENS
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
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Mailing Address - Street 1:11113 HOUZE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-998-1516
Mailing Address - Fax:770-998-1711
Practice Address - Street 1:11113 HOUZE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-998-1516
Practice Address - Fax:770-998-1711
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA327482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry