Provider Demographics
NPI:1194152983
Name:LIVING WATER CHRISTIAN COUNSELING CENTER
Entity type:Organization
Organization Name:LIVING WATER CHRISTIAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC.DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ELBERT
Authorized Official - Last Name:O'NEAL
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:586-954-0475
Mailing Address - Street 1:258 NB GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5749
Mailing Address - Country:US
Mailing Address - Phone:586-954-0475
Mailing Address - Fax:
Practice Address - Street 1:258 NB GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-5749
Practice Address - Country:US
Practice Address - Phone:586-954-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency