MEDICARE: HAVEN BEHAVIORAL SERVICES OF FT. WORTH, LLC

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	283Q00000X	Psychiatric Hospital

General Provider Information

NPI Number	:	1275974636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN BEHAVIORAL SERVICES OF FT. WORTH, LLC

Provider Business Mailing Address
First Line	:	652 W IRIS DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37204-3191
Country	:	US
Telephone Number	:	615-250-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 SAINT LOUIS AVE
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-3366
Country	:	US
Telephone Number	:	615-250-9500
Fax Number	:

Authorized Official
Title or Position	:	VP/TREASURER
Name	:	MRS. JANIE R PICKLE
Credential	:
Telephone Number	:	615-250-9064

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	07/15/2013

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