MEDICARE: GRACEFUL 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1841146495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEFUL HAVEN

Provider Business Mailing Address
First Line	:	5101 HAMPTON MEADOWS RD
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-9352
Country	:	US
Telephone Number	:	704-839-3260
Fax Number	:

Provider Business Practice Location Address
First Line	:	5101 HAMPTON MEADOWS RD
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-9352
Country	:	US
Telephone Number	:	704-839-3260
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICHELLE MONIQUE HEATH
Credential	:	HEATH
Telephone Number	:	704-839-3260

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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Directions to “GRACEFUL HAVEN ” Practice Location

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