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General NPI Number Information
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NPI Number | 1508308164
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Entity Type | Organization
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Legal Business Name | LIVING WATER COUNSELING CENTER
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Dates
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Enumeration Date | 11/14/2016
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Last Update Date | 11/14/2016
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Provider Practice Location Address
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Address Line | 1540 INTERNATIONAL PKWY
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City | LAKE MARY
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State | FL
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Zip | 32746-5096
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Country | US
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Telephone | 407-949-0209
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Fax | 844-549-5500
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Provider Business Mailing Address
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Address Line | 1540 INTERNATIONAL PKWY
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City | LAKE MARY
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State | FL
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Zip | 32746-5096
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Country | US
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Telephone | 407-949-0209
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Fax | 844-549-5500
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Authorized Official
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Title or Position | REGISTERED MARRIAGE AND FAMILY THER
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Name | MRS. SHARONDA WILLIAMS ENGRAM
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Credential | M.S.
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Telephone | 407-949-0209
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 106H00000X
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License Number State | FL
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