Healthcare Provider Details

I. General information

NPI: 1255273611
Provider Name (Legal Business Name): HAVEN OF PEACE ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LACOUR LN
EDGEWOOD NM
87015-6002
US

IV. Provider business mailing address

9 LACOUR LN
EDGEWOOD NM
87015-6002
US

V. Phone/Fax

Practice location:
  • Phone: 617-407-2460
  • Fax:
Mailing address:
  • Phone: 617-407-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY SCOTT
Title or Position: CEO
Credential:
Phone: 617-407-2460