=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578987517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STILL WATERS LIFE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2014
-----------------------------------------------------
Last Update Date | 02/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10277 VALLEY VIEW RD
-----------------------------------------------------
City | MACEDONIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44056-1740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-829-1788
-----------------------------------------------------
Fax | 440-888-1970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 347134
-----------------------------------------------------
City | PARMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44134-7134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-829-1788
-----------------------------------------------------
Fax | 440-888-1970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR/OWNER
-----------------------------------------------------
Name | MRS. CONNIE V CHROSNIAK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 440-829-1788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | C.0090570
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------