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General NPI Number Information
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NPI Number | 1902189723
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Entity Type | Organization
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Legal Business Name | HAVEN DEVELOPMENTAL CARE
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Dates
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Enumeration Date | 09/28/2011
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Last Update Date | 09/28/2011
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Provider Practice Location Address
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Address Line | 4794 MICHAEL JAY ST
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City | SNELLVILLE
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State | GA
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Zip | 30039-7630
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Country | US
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Telephone | 770-761-3402
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Fax | 770-679-4561
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Provider Business Mailing Address
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Address Line | 4794 MICHAEL JAY ST
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City | SNELLVILLE
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State | GA
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Zip | 30039-7630
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Country | US
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Telephone | 770-761-3402
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Fax | 770-679-4561
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Authorized Official
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Title or Position | DIRECTOR/CEO
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Name | MS. CAROL AGATHA TRIM-BAGOT
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Credential | MA
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Telephone | 770-761-3402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | CLA000738
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License Number State | GA
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