Provider Demographics
NPI:1740705177
Name:HETTIE'S HAVEN,LLC
Entity type:Organization
Organization Name:HETTIE'S HAVEN,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-586-4023
Mailing Address - Street 1:12108 RETFORD RD
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-5910
Mailing Address - Country:US
Mailing Address - Phone:276-393-2530
Mailing Address - Fax:
Practice Address - Street 1:12108 RETFORD RD
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230-5910
Practice Address - Country:US
Practice Address - Phone:276-393-2530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2839-01-001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities