Provider Demographics
NPI:1871087080
Name:GUARDIAN HAVEN ACADEMY
Entity type:Organization
Organization Name:GUARDIAN HAVEN ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAKISHA
Authorized Official - Middle Name:LAVELL
Authorized Official - Last Name:VARLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-400-2117
Mailing Address - Street 1:7853 GUNN HWY # 109
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1611
Mailing Address - Country:US
Mailing Address - Phone:813-400-2117
Mailing Address - Fax:
Practice Address - Street 1:5806 BRECKENRIDGE PKWY STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4211
Practice Address - Country:US
Practice Address - Phone:813-400-2117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100069300Medicaid