Provider Demographics
NPI:1902189723
Name:HAVEN DEVELOPMENTAL CARE
Entity Type:Organization
Organization Name:HAVEN DEVELOPMENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:AGATHA
Authorized Official - Last Name:TRIM-BAGOT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:770-761-3402
Mailing Address - Street 1:4794 MICHAEL JAY ST
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-7630
Mailing Address - Country:US
Mailing Address - Phone:770-761-3402
Mailing Address - Fax:770-679-4561
Practice Address - Street 1:4794 MICHAEL JAY ST
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-7630
Practice Address - Country:US
Practice Address - Phone:770-761-3402
Practice Address - Fax:770-679-4561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA000738251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health