Provider Demographics
NPI:1508308164
Name:LIVING WATER COUNSELING CENTER
Entity Type:Organization
Organization Name:LIVING WATER COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED MARRIAGE AND FAMILY THER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARONDA
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:ENGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:407-949-0209
Mailing Address - Street 1:1540 INTERNATIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5096
Mailing Address - Country:US
Mailing Address - Phone:407-949-0209
Mailing Address - Fax:844-549-5500
Practice Address - Street 1:1540 INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5096
Practice Address - Country:US
Practice Address - Phone:407-949-0209
Practice Address - Fax:844-549-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106H00000X305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service