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General NPI Number Information
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NPI Number | 1619144854
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Entity Type | Organization
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Legal Business Name | LIVING WATER PROGRAM
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 01/31/2017
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Provider Practice Location Address
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Address Line | 125 THOMAS GANTT RD
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City | HUNTINGTOWN
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State | MD
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Zip | 20639-8545
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Country | US
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Telephone | 301-855-1458
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Fax | 410-535-4505
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Provider Business Mailing Address
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Address Line | 125 THOMAS GANTT RD
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City | HUNTINGTOWN
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State | MD
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Zip | 20639-8545
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Country | US
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Telephone | 301-855-1458
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Fax | 410-535-4505
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Authorized Official
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Title or Position | CLINCIAL DIRECTOR
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Name | MRS. GLINDA C. ANDERSON
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Credential | MA
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Telephone | 301-855-1458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | MD10104401
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License Number State | MD
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