Provider Demographics
NPI:1619466489
Name:HAVEN OF HOPE, INC.
Entity Type:Organization
Organization Name:HAVEN OF HOPE, INC.
Other - Org Name:HAVEN OF HOPE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAVINA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CTRS
Authorized Official - Phone:831-345-2238
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-0610
Mailing Address - Country:US
Mailing Address - Phone:831-345-2238
Mailing Address - Fax:831-426-6348
Practice Address - Street 1:107 PAULINE DR
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-1063
Practice Address - Country:US
Practice Address - Phone:831-425-3010
Practice Address - Fax:831-426-6348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN OF HOPE, INC - HALCYON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445201743322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid