Provider Demographics
NPI:1023284320
Name:CHILDREN'S HAVEN COUNSELING SERVICES
Entity type:Organization
Organization Name:CHILDREN'S HAVEN COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR/OWN
Authorized Official - Prefix:MISS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RANDOLPH AUVENSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:817-446-5591
Mailing Address - Street 1:PO BOX 24511
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1511
Mailing Address - Country:US
Mailing Address - Phone:817-446-5591
Mailing Address - Fax:817-446-5591
Practice Address - Street 1:4200 SOUTH FWY STE 604
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1402
Practice Address - Country:US
Practice Address - Phone:817-446-5591
Practice Address - Fax:817-446-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19708252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1659549137Medicaid