Provider Demographics
NPI:1275638645
Name:STILLWATERS COUNSELING LLC
Entity Type:Organization
Organization Name:STILLWATERS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-782-0675
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0903
Mailing Address - Country:US
Mailing Address - Phone:208-782-0675
Mailing Address - Fax:208-782-0678
Practice Address - Street 1:1309 CAMAS ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3060
Practice Address - Country:US
Practice Address - Phone:208-782-0675
Practice Address - Fax:208-782-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-261187101YM0800X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806939500Medicaid