MEDICARE: ANNAHAVEN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1376085696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNAHAVEN LLC

Provider Business Mailing Address
First Line	:	410 STATE ST
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-3147
Country	:	US
Telephone Number	:	203-606-2071
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 STATE ST
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-3147
Country	:	US
Telephone Number	:	203-606-2071
Fax Number	:

Authorized Official
Title or Position	:	OWNER LICENCE CLINICAL SOCIAL WORKE
Name	:	ANNA C MARTIN
Credential	:	LCSW
Telephone Number	:	203-606-2071

Provider Enumeration Date	:	11/17/2016
Last Update Date	:	12/07/2016

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