Provider Demographics
NPI:1144303074
Name:CHILDHAVEN, INC
Entity type:Organization
Organization Name:CHILDHAVEN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:505-325-5358
Mailing Address - Street 1:807 W. APACHE ST.
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-325-5358
Mailing Address - Fax:505-327-1482
Practice Address - Street 1:807 W. APACHE ST.
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-5358
Practice Address - Fax:505-327-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCASE MANAGEMENT251B00000X
NM4151251S00000X, 253J00000X
NMTREATMENT FOSTER CAR251S00000X
NMTREATMENTFOSTER CARE253J00000X
NM251S00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3385Medicaid
NM21138761OtherMEDICAID