=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265846000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STILLWATERS COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 EAST HOLLYWOOD BOULEVARD BUILDING C, SUITE #C5
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-301-3525
-----------------------------------------------------
Fax | 850-301-3525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 EAST HOLLYWOOD BOULEVARD BUILDING C , SUITE #5
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-301-3525
-----------------------------------------------------
Fax | 850-301-3525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MS. KATHERINE IRENE FRECHETTE
-----------------------------------------------------
Credential | LMHC, LMFT
-----------------------------------------------------
Telephone | 850-301-3525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH4823
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT2651
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------