Healthcare Provider Details

I. General information

NPI: 1003480542
Provider Name (Legal Business Name): GRACEHAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 ARLINGTON CENTRE BLVD # 9B
COLUMBUS OH
43220-3075
US

IV. Provider business mailing address

5000 ARLINGTON CENTRE BLVD # 9B
COLUMBUS OH
43220-3075
US

V. Phone/Fax

Practice location:
  • Phone: 614-665-0665
  • Fax:
Mailing address:
  • Phone: 614-665-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER TABER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 614-665-0665