=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245106889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HAVEN SUPPORT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 RIVERSIDE PKWY NE STE 701
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-266-0756
-----------------------------------------------------
Fax | 706-625-7660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 RIVERSIDE PKWY NE STE 701
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-266-0756
-----------------------------------------------------
Fax | 706-625-7660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHEIF EXECUTIVE OFFICER
-----------------------------------------------------
Name | BRITTNY RAQUEL KINNEBREW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-266-0756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------