Provider Demographics
NPI:1467965335
Name:KIDSHEART COUNSELING, LLC
Entity Type:Organization
Organization Name:KIDSHEART COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:937-209-0088
Mailing Address - Street 1:1175 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8743
Mailing Address - Country:US
Mailing Address - Phone:937-642-3241
Mailing Address - Fax:
Practice Address - Street 1:463 ALLENBY DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8521
Practice Address - Country:US
Practice Address - Phone:937-209-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00089901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty