Provider Demographics
NPI:1780010876
Name:LIVING WATERS TRAUMA INSTITUTE, LLC
Entity Type:Organization
Organization Name:LIVING WATERS TRAUMA INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-577-4118
Mailing Address - Street 1:5828 MARIA DEL MAR ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-7299
Mailing Address - Country:US
Mailing Address - Phone:702-577-4118
Mailing Address - Fax:702-216-6000
Practice Address - Street 1:6130 ELTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2538
Practice Address - Country:US
Practice Address - Phone:702-577-4118
Practice Address - Fax:702-216-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5312-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty