Provider Demographics
NPI:1922445535
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
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:H
Authorized Official - Last Name:WOTTON
Authorized Official - Suffix:III
Authorized Official - Credentials:LICSE, LADC 1
Authorized Official - Phone:413-315-3194
Mailing Address - Street 1:94 SUFFOLK ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-4458
Mailing Address - Country:US
Mailing Address - Phone:413-315-3194
Mailing Address - Fax:413-322-8404
Practice Address - Street 1:94 SUFFOLK ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4458
Practice Address - Country:US
Practice Address - Phone:413-315-3194
Practice Address - Fax:413-322-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1145161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA241903OtherTUFT
MAP09114OtherBLUE CROSS BLUE SHIELD
MA109497OtherBEACON
MA45208OtherHEALTH NEW ENGLAND
MA0005602OtherMEDICARE
MA6724849OtherAETNA