Provider Demographics
NPI:1619718038
Name:STILL WATER SERENITY FOUNDATION LLC
Entity type:Organization
Organization Name:STILL WATER SERENITY FOUNDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITTAKER
Authorized Official - Suffix:
Authorized Official - Credentials:APN, FNP
Authorized Official - Phone:860-387-7940
Mailing Address - Street 1:133 LONGMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-4170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 LONGMEADOW DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4170
Practice Address - Country:US
Practice Address - Phone:860-387-7940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty