Healthcare Provider Details

I. General information

NPI: 1265416994
Provider Name (Legal Business Name): HAVEN HOUSE, INC .
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 AUGUSTINE HERMAN HWY
ELKTON MD
21921-8252
US

IV. Provider business mailing address

1195 AUGUSTINE HERMAN HWY PO BOX 723
ELKTON MD
21921-8252
US

V. Phone/Fax

Practice location:
  • Phone: 410-398-9900
  • Fax:
Mailing address:
  • Phone: 410-398-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number8314
License Number StateMD

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 443-839-6928