Provider Demographics
NPI:1619144854
Name:LIVING WATER PROGRAM
Entity Type:Organization
Organization Name:LIVING WATER PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCIAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:301-855-1458
Mailing Address - Street 1:125 THOMAS GANTT RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-8545
Mailing Address - Country:US
Mailing Address - Phone:301-855-1458
Mailing Address - Fax:410-535-4505
Practice Address - Street 1:125 THOMAS GANTT RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-8545
Practice Address - Country:US
Practice Address - Phone:301-855-1458
Practice Address - Fax:410-535-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD10104401101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4004523Medicaid