=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740995505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE HAVEN ABA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2023
-----------------------------------------------------
Last Update Date | 01/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15622 GOLFVIEW DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-493-2445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15622 GOLFVIEW DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-493-2445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS MARSHAYLA BROWN
-----------------------------------------------------
Credential | M.ED., BCBA., LBA
-----------------------------------------------------
Telephone | 734-493-2445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------