Healthcare Provider Details

I. General information

NPI: 1568949329
Provider Name (Legal Business Name): A SAFE HAVEN, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W ROOSEVELT RD
CHICAGO IL
60608-1094
US

IV. Provider business mailing address

15507 CICERO AVE STE 200
OAK FOREST IL
60452-3633
US

V. Phone/Fax

Practice location:
  • Phone: 312-372-6707
  • Fax:
Mailing address:
  • Phone: 773-435-8429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE DZADO
Title or Position: ADMIN
Credential:
Phone: 312-372-6707