Healthcare Provider Details

I. General information

NPI: 1144303074
Provider Name (Legal Business Name): CHILDHAVEN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 W. APACHE ST.
FARMINGTON NM
87401
US

IV. Provider business mailing address

807 W. APACHE ST.
FARMINGTON NM
87401
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-5358
  • Fax: 505-327-1482
Mailing address:
  • Phone: 505-325-5358
  • Fax: 505-327-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberCASE MANAGEMENT
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4151
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberTREATMENT FOSTER CAR
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberTREATMENTFOSTER CARE
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNM
# 7
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number4151
License Number StateNM

VIII. Authorized Official

Name: DIANE DEAN
Title or Position: CFO
Credential: CPA
Phone: 505-325-5358