Provider Demographics
NPI:1063607653
Name:HAVEN OF SAFETY, INC.
Entity type:Organization
Organization Name:HAVEN OF SAFETY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WINIFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLE-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-534-6720
Mailing Address - Street 1:4379 LUXEMBOURG DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5428
Mailing Address - Country:US
Mailing Address - Phone:404-534-6720
Mailing Address - Fax:404-534-6722
Practice Address - Street 1:4150 SNAPFINGER WOODS DR
Practice Address - Street 2:SUITE 208
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3417
Practice Address - Country:US
Practice Address - Phone:404-534-6720
Practice Address - Fax:404-534-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
GA044645D101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4279383701100OtherMHDDAD PROVIDER AGREEMENT