=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023284320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S HAVEN COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2008
-----------------------------------------------------
Last Update Date | 05/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 SOUTH FWY STE 604
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76115-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-446-5591
-----------------------------------------------------
Fax | 817-446-5591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 24511
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76124-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-446-5591
-----------------------------------------------------
Fax | 817-446-5591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR/OWN
-----------------------------------------------------
Name | MISS MONICA LYNN RANDOLPH AUVENSHINE
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 817-446-5591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 19708
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------