Healthcare Provider Details

I. General information

NPI: 1518839372
Provider Name (Legal Business Name): HAVENPATH SUPPORTIVE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4518 W MARKET ST STE A
GREENSBORO NC
27407-1543
US

IV. Provider business mailing address

4518 W MARKET ST STE A
GREENSBORO NC
27407-1543
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-5250
  • Fax:
Mailing address:
  • Phone: 704-662-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. ROOSEVELT SMITH
Title or Position: OWNER
Credential:
Phone: 704-662-5250