MEDICARE: ASPIRE HAVEN GROUP HOMES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	251S00000X	Community/Behavioral Health Agency
3	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
4	372600000X	Adult Companion
5	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1568293017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASPIRE HAVEN GROUP HOMES

Provider Business Mailing Address
First Line	:	PO BOX 683
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-0018
Country	:	US
Telephone Number	:	770-318-2828
Fax Number	:	888-846-6014

Provider Business Practice Location Address
First Line	:	12708 SAN JOSE BLVD STE 1A
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-2600
Country	:	US
Telephone Number	:	770-318-2828
Fax Number	:	888-846-6014

Authorized Official
Title or Position	:	BCBA/ CFO
Name	:	TANISHA OKONJI
Credential	:	M.ED.
Telephone Number	:	770-905-2521

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/07/2024

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Directions to “ASPIRE HAVEN GROUP HOMES ” Practice Location

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