1104335470 NPI number — STILL WATERS COUNSELING

Table of content: (NPI 1104335470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104335470 NPI number — STILL WATERS COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STILL WATERS COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104335470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
427 F ST STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95501-1040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-834-5408
Provider Business Mailing Address Fax Number:
707-443-4519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2910 HARRIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95503-4811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-834-5408
Provider Business Practice Location Address Fax Number:
707-443-4519
Provider Enumeration Date:
09/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BLODGETT
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
707-834-5408

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1285969436 . This is a "BOARD OF BEHAVIORAL SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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