Provider Demographics
NPI:1871388280
Name:STILL WATERS LCSW PLLC
Entity type:Organization
Organization Name:STILL WATERS LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THERON
Authorized Official - Middle Name:DE-WITT
Authorized Official - Last Name:ISON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-564-3552
Mailing Address - Street 1:16005 76TH AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1108
Mailing Address - Country:US
Mailing Address - Phone:347-564-3552
Mailing Address - Fax:
Practice Address - Street 1:16005 76TH AVE APT 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11366-1108
Practice Address - Country:US
Practice Address - Phone:347-564-3552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty