MEDICARE: HEAVENLY HAVEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295284727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY HAVEN

Provider Business Mailing Address
First Line	:	4748 CLOVER ST
Second Line	:	UNIT A
City	:	HOUSTON
State	:	TX
Zip	:	77033-4047
Country	:	US
Telephone Number	:	832-433-8433
Fax Number	:

Provider Business Practice Location Address
First Line	:	4748 CLOVER ST
Second Line	:	UNIT A
City	:	HOUSTON
State	:	TX
Zip	:	77033-4047
Country	:	US
Telephone Number	:	832-433-8433
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	ANDREA DYER
Credential	:
Telephone Number	:	832-433-8433

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	09/26/2016

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1871044925 — HEAVENLY HAVEN
Practice Location Address:

4748 CLOVER ST , UNIT A
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1285688382 — WILLIAM JEFFREY FRACE, M.D.
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Directions to “HEAVENLY HAVEN ” Practice Location

Language	Start Address	Practice Location

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