Provider Demographics
NPI:1285901058
Name:LIVING WATERS COUNSELING
Entity type:Organization
Organization Name:LIVING WATERS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MANZON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-348-0956
Mailing Address - Street 1:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2588
Mailing Address - Country:US
Mailing Address - Phone:269-492-3801
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:5955 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8700
Practice Address - Country:US
Practice Address - Phone:269-348-0956
Practice Address - Fax:269-353-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009199103TC1900X
MI6801059772104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty