Healthcare Provider Details

I. General information

NPI: 1487805537
Provider Name (Legal Business Name): WATERLEAF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 CAMPBELL ST
VALPARAISO IN
46385-1773
US

IV. Provider business mailing address

815 MAIN ST SUITE 1D
SAINT JOSEPH MI
49085-1473
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-9000
  • Fax: 219-462-9000
Mailing address:
  • Phone: 269-982-4055
  • Fax: 219-462-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA DENISE LEEMASTER
Title or Position: PRESIDENT/OWNER
Credential: LCSW, ACSW
Phone: 269-449-7809