Provider Demographics
NPI:1578987517
Name:STILL WATERS LIFE CENTER, LLC
Entity Type:Organization
Organization Name:STILL WATERS LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:CHROSNIAK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:440-829-1788
Mailing Address - Street 1:PO BOX 347134
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-7134
Mailing Address - Country:US
Mailing Address - Phone:440-829-1788
Mailing Address - Fax:440-888-1970
Practice Address - Street 1:10277 VALLEY VIEW RD
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-1740
Practice Address - Country:US
Practice Address - Phone:440-829-1788
Practice Address - Fax:440-888-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0090570251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health