Provider Demographics
NPI:1619264892
Name:LIVING WATER COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:LIVING WATER COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-534-9329
Mailing Address - Street 1:412 RUNNER STONE DR
Mailing Address - Street 2:
Mailing Address - City:EVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24550-4330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:137 LAXTON RD
Practice Address - Street 2:SUITE 250
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3144
Practice Address - Country:US
Practice Address - Phone:434-473-7458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVING WATER COUNSELING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-07
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101Y00000X
VA1913251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty