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General NPI Number Information
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NPI Number | 1588182984
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Entity Type | Organization
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Legal Business Name | WATER CUP COUNSELING
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Dates
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Enumeration Date | 09/06/2017
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Last Update Date | 09/06/2017
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Provider Practice Location Address
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Address Line | 852 SW 15TH ST
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City | REDMOND
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State | OR
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Zip | 97756-2507
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Country | US
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Telephone | 541-527-5802
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Fax | 541-526-0300
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Provider Business Mailing Address
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Address Line | 2318 SE JEFFERSON DR
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City | PRINEVILLE
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State | OR
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Zip | 97754-8891
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Country | US
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Telephone | 541-527-5802
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Fax |
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Authorized Official
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Title or Position | LMFT THERAPIST.
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Name | DR. BARRY WILLIAM GRIDLEY
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Credential | D.MIN.
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Telephone | 541-527-5802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | T-1233
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License Number State | OR
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