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General NPI Number Information
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NPI Number | 1144046608
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Entity Type | Organization
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Legal Business Name | HEALING HAVEN LICENSED CLINICAL
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Dates
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Enumeration Date | 12/02/2024
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 315 E ESPLANADE AVE UNIT 89
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City | SAN JACINTO
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State | CA
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Zip | 92583-5102
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Country | US
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Telephone | 951-214-5071
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Fax |
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Provider Business Mailing Address
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Address Line | 315 E ESPLANADE AVE UNIT 89
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City | SAN JACINTO
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State | CA
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Zip | 92583-5102
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Country | US
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Telephone | 951-214-5071
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | KENYADA M WAGONER
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Credential | LCSW
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Telephone | 951-214-5071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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