=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689113227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN WATERS COUNSELING GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2017
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 ARBOR LN
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-340-2131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 ARBOR LN
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-340-2131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICIAN
-----------------------------------------------------
Name | MRS. DAWN ELIZABETH WATERS
-----------------------------------------------------
Credential | MA, LPC, NCC
-----------------------------------------------------
Telephone | 989-340-2131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6401015574
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------