Provider Demographics
NPI:1134130909
Name:GRACE HAVEN MANAGEMENT, INC.
Entity Type:Organization
Organization Name:GRACE HAVEN MANAGEMENT, INC.
Other - Org Name:GRACE HAVEN HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO/PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLYN
Authorized Official - Middle Name:CLEVERT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-779-2356
Mailing Address - Street 1:PO BOX 2012
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-0010
Mailing Address - Country:US
Mailing Address - Phone:804-779-2356
Mailing Address - Fax:804-779-7566
Practice Address - Street 1:6111 MAGAZINE DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-4540
Practice Address - Country:US
Practice Address - Phone:804-779-2356
Practice Address - Fax:804-779-7566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
VASS-269-06320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010217245Medicaid