Healthcare Provider Details

I. General information

NPI: 1902663172
Provider Name (Legal Business Name): SERENITY HAVEN RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4734 LIDDELL SHORTCUT RD
SEVEN SPRINGS NC
28578-9469
US

IV. Provider business mailing address

4734 LIDDELL SHORTCUT RD
SEVEN SPRINGS NC
28578-9469
US

V. Phone/Fax

Practice location:
  • Phone: 336-402-1527
  • Fax:
Mailing address:
  • Phone: 336-402-1527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MELISSA ANN GOYEN
Title or Position: OWNER/CEO
Credential: LQMHP, LCAS, CCS-I
Phone: 336-402-1527