Provider Demographics
NPI:1134617798
Name:HAVEN OF HOPE, INC.
Entity type:Organization
Organization Name:HAVEN OF HOPE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DAVINA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CTRS
Authorized Official - Phone:831-425-3010
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
Practice Address - Country:US
Practice Address - Phone:831-345-2238
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:2018-04-28
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445200555322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children