Basic Information
| Provider Information | |||||||||
| NPI: | 1215538111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOPE & HAVEN FAMILY SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 644 N COUNTRY CLUB DR STE C | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852014983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736618193 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N SCOTTSDALE RD UNIT 4222 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852517262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736618193 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2020 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PENNIX | ||||||||
| AuthorizedOfficialFirstName: | LASHONIA | ||||||||
| AuthorizedOfficialMiddleName: | SHASHERAH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7736618193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OWNER | ||||||||
| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00000000 | 05 | AZ | MEDICAID |