MEDICARE: GRACE HAVEN HOME 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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1952253163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE HAVEN HOME LLC

Provider Business Mailing Address
First Line	:	4767 HOUSTON RD APT 3113
Second Line	:
City	:	FLORENCE
State	:	KY
Zip	:	41042-4815
Country	:	US
Telephone Number	:	678-368-0359
Fax Number	:

Provider Business Practice Location Address
First Line	:	4767 HOUSTON RD APT 3113
Second Line	:
City	:	FLORENCE
State	:	KY
Zip	:	41042-4815
Country	:	US
Telephone Number	:	678-368-0359
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LENA BREWER
Credential	:
Telephone Number	:	678-368-0359

Provider Enumeration Date	:	02/11/2026
Last Update Date	:	02/11/2026

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