=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487334264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERSHED WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2023
-----------------------------------------------------
Last Update Date | 07/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 E LAKE ST STE 205
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-304-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 S LAVINA AVE
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-304-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DAVID BARTH
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 208-304-1102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------