Healthcare Provider Details

I. General information

NPI: 1720990740
Provider Name (Legal Business Name): HAVEN GRACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

13480 SE 132ND AVE
CLACKAMAS OR
97015-9338
US

IV. Provider business mailing address

10399 SE CRESCENT RIDGE DR
HAPPY VALLEY OR
97086-9100
US

V. Phone/Fax

Practice location:
  • Phone: 574-551-5277
  • Fax:
Mailing address:
  • Phone: 574-551-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY ALLEN SMITH
Title or Position: PROVIDER
Credential:
Phone: 574-551-5277