Healthcare Provider Details

I. General information

NPI: 1699516534
Provider Name (Legal Business Name): LIVING WATER RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SPURGEON DR
MONROE LA
71203-4521
US

IV. Provider business mailing address

PO BOX 7563
MONROE LA
71211-7563
US

V. Phone/Fax

Practice location:
  • Phone: 318-614-7644
  • Fax:
Mailing address:
  • Phone: 318-278-5964
  • Fax: 318-343-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LASHUNTA SHARLAN PRINGLE
Title or Position: ADMIN. CREDENTIALING COORDINATOR
Credential:
Phone: 318-278-5964