Provider Demographics
NPI:1477833135
Name:CHILDREN'S CRISIS PREVENTION NETWORK, INC.
Entity Type:Organization
Organization Name:CHILDREN'S CRISIS PREVENTION NETWORK, INC.
Other - Org Name:COMMUNITY CARE & PREVENTION NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:903-677-3220
Mailing Address - Street 1:PO BOX 2464
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-7464
Mailing Address - Country:US
Mailing Address - Phone:903-677-3220
Mailing Address - Fax:903-677-0710
Practice Address - Street 1:7479 STATE HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-8979
Practice Address - Country:US
Practice Address - Phone:903-677-3220
Practice Address - Fax:903-677-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPA- 12381101Y00000X
TXLCDC- 11123101YA0400X
TXCCDS- 0831-0991101YA0400X
TXLCDC- 6684101YA0400X
TXLCDC- 1066101YA0400X
TXLPC- 20058101YM0800X, 101YP2500X
TXLPC- 19613101YP2500X
TXLSSP-S 6100-S101YP2500X
TXLPC- 15979101YP2500X
TXLPC- 9187101YP2500X
TXLPC- 19349101YP2500X
TXLPC-S 13026101YP2500X
TXLSSP- 30134103TS0200X
TXLMFT- 000088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty