Healthcare Provider Details

I. General information

NPI: 1083362768
Provider Name (Legal Business Name): 4HEALING HEARTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2022
Last Update Date: 03/12/2022
Certification Date: 03/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 GREENDALE CT
FORT WORTH TX
76112-3410
US

IV. Provider business mailing address

PO BOX 8006
FORT WORTH TX
76124-0006
US

V. Phone/Fax

Practice location:
  • Phone: 817-680-7912
  • Fax: 817-887-2415
Mailing address:
  • Phone: 817-680-7912
  • Fax: 817-887-2415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TYIESHA BROWN
Title or Position: ADMINISTRATOR
Credential:
Phone: 817-680-7912