Provider Demographics
NPI:1609381631
Name:STILL WATER PROFESSIONAL COUNSELING, LLC
Entity Type:Organization
Organization Name:STILL WATER PROFESSIONAL COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOOTHROYD
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:989-832-0191
Mailing Address - Street 1:5100 EASTMAN AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640
Mailing Address - Country:US
Mailing Address - Phone:989-832-0191
Mailing Address - Fax:989-486-9413
Practice Address - Street 1:5100 EASTMAN AVE
Practice Address - Street 2:STE 2
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-832-0191
Practice Address - Fax:989-486-9413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013357101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty