Healthcare Provider Details

I. General information

NPI: 1376194324
Provider Name (Legal Business Name): LIVING WATER SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2019
Last Update Date: 09/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 FORBES BLVD STE 130
LANHAM MD
20706-4375
US

IV. Provider business mailing address

8217 KIPPIS RD
MILLERSVILLE MD
21108-1821
US

V. Phone/Fax

Practice location:
  • Phone: 202-559-9344
  • Fax:
Mailing address:
  • Phone: 202-460-6876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE THOMAS
Title or Position: PRESIDENT
Credential:
Phone: 202-460-6876