Provider Demographics
NPI:1851590558
Name:SAFE HAVEN CHILD AND FAMILY COUNSELING SERVICES,LLC
Entity Type:Organization
Organization Name:SAFE HAVEN CHILD AND FAMILY COUNSELING SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:COSSSANDRA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-763-9555
Mailing Address - Street 1:1426 JUNIPER HILLS LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7740
Mailing Address - Country:US
Mailing Address - Phone:704-763-9555
Mailing Address - Fax:
Practice Address - Street 1:4822 ALBEMARLE RD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6612
Practice Address - Country:US
Practice Address - Phone:704-763-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC005101251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005705Medicaid