1831682459 NPI number — STILL WATERS THERAPY PLLC

Table of content: (NPI 1831682459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831682459 NPI number — STILL WATERS THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STILL WATERS THERAPY PLLC
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:
1831682459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLY RIDGE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28445-0421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-622-3418
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13480 HWY 50/210
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
SURF CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28445-8609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-622-3418
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MANN
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED CLINICIAN SOCIAL WORKER
Authorized Official Telephone Number:
910-622-3418

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C010307 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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