MEDICARE: CONNECTION HAVEN THERAPY, LLC

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1376213009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTION HAVEN THERAPY, LLC

Provider Business Mailing Address
First Line	:	2032 HATTON CT
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-9834
Country	:	US
Telephone Number	:	404-429-1113
Fax Number	:

Provider Business Practice Location Address
First Line	:	3839 MARTINEZ BLVD STE 2
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-2666
Country	:	US
Telephone Number	:	706-310-5153
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	CASSANDRE ELENA HUDSON
Credential	:	LCSW
Telephone Number	:	706-310-5153

Provider Enumeration Date	:	09/14/2021
Last Update Date	:	05/16/2024

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