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General NPI Number Information
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NPI Number | 1023534294
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Entity Type | Organization
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Legal Business Name | DEEP WATERS AUSTIN LLC
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Dates
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Enumeration Date | 08/18/2017
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Last Update Date | 08/18/2017
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Provider Practice Location Address
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Address Line | 13740 RESEARCH BLVD STE N8
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City | AUSTIN
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State | TX
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Zip | 78750-1834
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Country | US
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Telephone | 512-939-7769
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Fax | 512-939-7769
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Provider Business Mailing Address
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Address Line | 312 BRENTWOOD DR
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City | LEANDER
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State | TX
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Zip | 78641-9431
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Country | US
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Telephone | 512-939-7769
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JENNIFER MERRILL BACA DAVILA
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Credential | LPC
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Telephone | 512-939-7769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 71881
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License Number State | TX
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