Provider Demographics
NPI:1265416994
Name:HAVEN HOUSE, INC .
Entity type:Organization
Organization Name:HAVEN HOUSE, INC .
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-839-6928
Mailing Address - Street 1:1195 AUGUSTINE HERMAN HWY
Mailing Address - Street 2:PO BOX 723
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-8252
Mailing Address - Country:US
Mailing Address - Phone:410-398-9900
Mailing Address - Fax:
Practice Address - Street 1:1195 AUGUSTINE HERMAN HWY
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-8252
Practice Address - Country:US
Practice Address - Phone:410-398-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8314324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility