Provider Demographics
NPI:1811450646
Name:LIVING WATERS PEACE CENTER
Entity type:Organization
Organization Name:LIVING WATERS PEACE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MENTAL HEALTH COUNSELOR ASSOC
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHCA
Authorized Official - Phone:260-230-1180
Mailing Address - Street 1:3262 MALLARD COVE LN STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:260-230-1180
Mailing Address - Fax:
Practice Address - Street 1:3262 MALLARD COVE LN STE B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2883
Practice Address - Country:US
Practice Address - Phone:260-230-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty