Healthcare Provider Details

I. General information

NPI: 1134130909
Provider Name (Legal Business Name): GRACE HAVEN MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 MAGAZINE DR
MECHANICSVILLE VA
23111-4540
US

IV. Provider business mailing address

PO BOX 2012
MECHANICSVILLE VA
23116-0010
US

V. Phone/Fax

Practice location:
  • Phone: 804-779-2356
  • Fax: 804-779-7566
Mailing address:
  • Phone: 804-779-2356
  • Fax: 804-779-7566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberSS-269-06
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. KARLYN CLEVERT SMITH
Title or Position: CAO/PROGRAM DIRECTOR
Credential:
Phone: 804-779-2356