Provider Demographics
NPI:1710017793
Name:STILL WATERS PROFESSIONAL COUNSELING SERVICES, INC.
Entity Type:Organization
Organization Name:STILL WATERS PROFESSIONAL COUNSELING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LEANN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:OLDFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-955-9224
Mailing Address - Street 1:3711 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0951
Mailing Address - Country:US
Mailing Address - Phone:706-955-9224
Mailing Address - Fax:706-955-9349
Practice Address - Street 1:3711 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0951
Practice Address - Country:US
Practice Address - Phone:706-955-9224
Practice Address - Fax:706-955-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA417703382AMedicaid