Healthcare Provider Details

I. General information

NPI: 1760644041
Provider Name (Legal Business Name): STILLWATER CENTER FOR FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 S TAYLOR ST
FALLON NV
89406-3261
US

IV. Provider business mailing address

PO BOX 370
FALLON NV
89407-0370
US

V. Phone/Fax

Practice location:
  • Phone: 775-867-4123
  • Fax: 775-867-4914
Mailing address:
  • Phone: 775-867-4123
  • Fax: 775-867-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0436
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2940-C
License Number StateNV

VIII. Authorized Official

Name: CAROL JUUL
Title or Position: LICXENSED CLINICAL SOCIAL WORKER
Credential:
Phone: 775-867-4123