Provider Demographics
NPI:1134787989
Name:STILLWATER CENTER FOR WELLNESS PC
Entity type:Organization
Organization Name:STILLWATER CENTER FOR WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-303-5331
Mailing Address - Street 1:701 S DURKIN DR STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6030
Mailing Address - Country:US
Mailing Address - Phone:217-726-7575
Mailing Address - Fax:217-726-7577
Practice Address - Street 1:435 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5006
Practice Address - Country:US
Practice Address - Phone:217-303-5331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STILLWATER CENTER FOR WELLNESS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty