Provider Demographics
NPI:1811292642
Name:INLIGHTENED SAFE HAVEN
Entity type:Organization
Organization Name:INLIGHTENED SAFE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-782-1517
Mailing Address - Street 1:828 NTH 28TH ST.
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630
Mailing Address - Country:US
Mailing Address - Phone:409-670-1803
Mailing Address - Fax:409-670-1803
Practice Address - Street 1:828 NTH 28TH ST.
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630
Practice Address - Country:US
Practice Address - Phone:409-670-1803
Practice Address - Fax:409-670-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05785017171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid