Healthcare Provider Details

I. General information

NPI: 1083594451
Provider Name (Legal Business Name): HEALING WATERS MARRIAGE AND FAMILY THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16031 TUSCOLA RD
APPLE VALLEY CA
92307-1319
US

IV. Provider business mailing address

16031 TUSCOLA RD
APPLE VALLEY CA
92307-1319
US

V. Phone/Fax

Practice location:
  • Phone: 661-209-3614
  • Fax: 661-524-9950
Mailing address:
  • Phone: 661-209-3614
  • Fax: 661-524-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE SEGROVES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 661-874-7851