Basic Information
Provider Information | |||||||||
NPI: | 1972980514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIVING WATER MINISTRIES INTERNATIONAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIVING WATER FAMILY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7563 | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712117563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186147644 | ||||||||
FaxNumber: | 3183429347 | ||||||||
Practice Location | |||||||||
Address1: | 1816 ROSELAWN AVENUE | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 71201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3183255898 | ||||||||
FaxNumber: | 3183429347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2015 | ||||||||
LastUpdateDate: | 05/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FISHER | ||||||||
AuthorizedOfficialFirstName: | LATONDRA | ||||||||
AuthorizedOfficialMiddleName: | CARLETTE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3186147644 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.