Provider Demographics
NPI:1972150159
Name:LIVING WATER BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:LIVING WATER BEHAVIORAL HEALTH LLC
Other - Org Name:LIVING WATER BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAMSI
Authorized Official - Middle Name:
Authorized Official - Last Name:NWANKWOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-228-6258
Mailing Address - Street 1:335 KLAGG AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-4419
Mailing Address - Country:US
Mailing Address - Phone:609-228-6258
Mailing Address - Fax:609-423-0210
Practice Address - Street 1:335 KLAGG AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4419
Practice Address - Country:US
Practice Address - Phone:609-228-6258
Practice Address - Fax:609-423-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ504941AH7LMedicaid