Provider Demographics
NPI:1891843009
Name:UNIQUE HAVEN RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:UNIQUE HAVEN RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALETHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCELLUS
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR PSYCHOLOGY
Authorized Official - Phone:919-306-1469
Mailing Address - Street 1:PO BOX 713
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-0713
Mailing Address - Country:US
Mailing Address - Phone:919-528-7439
Mailing Address - Fax:
Practice Address - Street 1:608 YOUNG ST
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-8347
Practice Address - Country:US
Practice Address - Phone:919-528-7439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-07
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-039-043320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805713Medicaid