Provider Demographics
NPI:1851610760
Name:STILL WATERS COUNSELING
Entity Type:Organization
Organization Name:STILL WATERS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-782-0675
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0903
Mailing Address - Country:US
Mailing Address - Phone:208-782-0675
Mailing Address - Fax:208-782-0678
Practice Address - Street 1:1309 CAMAS ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3060
Practice Address - Country:US
Practice Address - Phone:208-782-0675
Practice Address - Fax:208-782-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW261187261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8084327Medicaid