MEDICARE: CHILDREN'S HAVEN COUNSELING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	19708	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023284320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S HAVEN COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 24511
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76124-1511
Country	:	US
Telephone Number	:	817-446-5591
Fax Number	:	817-446-5591

Provider Business Practice Location Address
First Line	:	4200 SOUTH FWY STE 604
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-1402
Country	:	US
Telephone Number	:	817-446-5591
Fax Number	:	817-446-5591

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR/OWN
Name	:	MISS MONICA LYNN RANDOLPH AUVENSHINE
Credential	:	MA, LPC
Telephone Number	:	817-446-5591

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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