Provider Demographics
NPI:1215153432
Name:LIVING WATERS COORDINATED COMMUNITIES, INC.
Entity type:Organization
Organization Name:LIVING WATERS COORDINATED COMMUNITIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVERL
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-676-0926
Mailing Address - Street 1:212 W IRONWOOD DR
Mailing Address - Street 2:SUITE D311
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1403
Mailing Address - Country:US
Mailing Address - Phone:208-676-0926
Mailing Address - Fax:208-676-0926
Practice Address - Street 1:2108 N IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-676-0926
Practice Address - Fax:208-676-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSYCHOLOGY 202060261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1684419Medicare ID - Type UnspecifiedPSYCHOLOGY