Healthcare Provider Details

I. General information

NPI: 1124762083
Provider Name (Legal Business Name): LIVING WATERS COUNSELING AND WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 WINDY HILL DR STE 14B
RALEIGH NC
27609-5193
US

IV. Provider business mailing address

3886 LITTLE CREEK CHURCH RD
CLAYTON NC
27520-9536
US

V. Phone/Fax

Practice location:
  • Phone: 984-212-4619
  • Fax: 252-600-0454
Mailing address:
  • Phone:
  • Fax:

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MBATA-GRAHAM
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 919-521-2057