Healthcare Provider Details

I. General information

NPI: 1710426036
Provider Name (Legal Business Name): THREE WATERS RECOVERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STERN RD
SEAMAN OH
45679-9607
US

IV. Provider business mailing address

6722 STATE ROUTE 132 STE A
GOSHEN OH
45122-9346
US

V. Phone/Fax

Practice location:
  • Phone: 513-967-1460
  • Fax: 513-456-2855
Mailing address:
  • Phone: 513-575-7879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MELINDA M ADAMS
Title or Position: OWNER/ DIRECTOR
Credential: MA.
Phone: 513-967-1460