Provider Demographics
NPI:1184378143
Name:ROUSCH-CARLISLE, CHAVA SHIRA (LCSW, APHSW-C)
Entity type:Individual
Prefix:
First Name:CHAVA
Middle Name:SHIRA
Last Name:ROUSCH-CARLISLE
Suffix:
Gender:F
Credentials:LCSW, APHSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 W PIPELINE RD # 103
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-4629
Mailing Address - Country:US
Mailing Address - Phone:817-692-6917
Mailing Address - Fax:
Practice Address - Street 1:3210 W PARK ROW DR
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-3136
Practice Address - Country:US
Practice Address - Phone:817-692-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
TX637731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional