Healthcare Provider Details

I. General information

NPI: 1972407229
Provider Name (Legal Business Name): GLENN HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6417 SPANISH MOSS LN
CHARLOTTE NC
28262-2259
US

IV. Provider business mailing address

6417 SPANISH MOSS LN
CHARLOTTE NC
28262-2259
US

V. Phone/Fax

Practice location:
  • Phone: 803-412-9514
  • Fax:
Mailing address:
  • Phone: 803-412-9514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANA KEITT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 803-412-9514