Healthcare Provider Details

I. General information

NPI: 1184362303
Provider Name (Legal Business Name): THE EMPRESS HAVEN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 FAYETTEVILLE ST
DURHAM NC
27707-4175
US

IV. Provider business mailing address

3 OLIVENE DR
DURHAM NC
27703-6755
US

V. Phone/Fax

Practice location:
  • Phone: 919-724-9733
  • Fax:
Mailing address:
  • Phone: 919-724-9733
  • 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 Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MYISHANKA MCMILLIAN
Title or Position: CEO/FOUNDER
Credential: LCMHC
Phone: 919-724-9733