Provider Demographics
NPI:1346932555
Name:KESEWA SAFE HAVEN
Entity type:Organization
Organization Name:KESEWA SAFE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:NANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAMFO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-997-5863
Mailing Address - Street 1:520 W MESA AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3285
Mailing Address - Country:US
Mailing Address - Phone:909-997-5863
Mailing Address - Fax:
Practice Address - Street 1:229 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6467
Practice Address - Country:US
Practice Address - Phone:190-999-7586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No252Y00000XAgenciesEarly Intervention Provider Agency
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center