Healthcare Provider Details

I. General information

NPI: 1942746961
Provider Name (Legal Business Name): BEHAVEN WELLNESS RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 HAVEN CREST DR
POWDER SPRINGS GA
30127-4966
US

IV. Provider business mailing address

1532 HAVEN CREST DR
POWDER SPRINGS GA
30127-4966
US

V. Phone/Fax

Practice location:
  • Phone: 770-576-5604
  • Fax:
Mailing address:
  • Phone: 770-576-5604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: OLUMAYOWA OJEMUYIWA
Title or Position: WHAM, CPS, PP
Credential:
Phone: 770-576-5604