Provider Demographics
NPI:1417619446
Name:CLEARWATER EMDR LLC
Entity Type:Organization
Organization Name:CLEARWATER EMDR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAGEDES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:727-316-5740
Mailing Address - Street 1:2430 ESTANCIA BLVD STE 100A
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2644
Mailing Address - Country:US
Mailing Address - Phone:727-316-5740
Mailing Address - Fax:833-216-5165
Practice Address - Street 1:2430 ESTANCIA BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2644
Practice Address - Country:US
Practice Address - Phone:727-316-5740
Practice Address - Fax:833-216-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)