Healthcare Provider Details

I. General information

NPI: 1982553079
Provider Name (Legal Business Name): GRACE HAVEN BEHAVIORAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE STE N
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE STE N
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 844-914-7223
  • Fax:
Mailing address:
  • Phone: 844-914-7223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: RICKIE STANDIFER
Title or Position: CEO
Credential:
Phone: 480-765-0866