Provider Demographics
NPI:1518097997
Name:STILL WATERS COUNSELING
Entity Type:Organization
Organization Name:STILL WATERS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-782-0675
Mailing Address - Street 1:1309 CAMAS ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3060
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:2007-03-06
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 26187251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807352800Medicaid