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General NPI Number Information
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NPI Number | 1699261990
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Entity Type | Organization
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Legal Business Name | STILL WATERS COUNSELING
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Dates
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Enumeration Date | 07/10/2018
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Last Update Date | 07/10/2018
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Provider Practice Location Address
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Address Line | 442 NW WADE STREET
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City | ESTACADA
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State | OR
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Zip | 97023
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Country | US
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Telephone | 541-561-8127
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Fax |
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Provider Business Mailing Address
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Address Line | 442 NW WADE ST
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City | ESTACADA
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State | OR
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Zip | 97023-9744
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Country | US
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Telephone | 541-561-8127
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | ANTONIO CLIFTON LONG-DREW
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Credential | REGISTERED LPC INTER
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Telephone | 541-561-8127
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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 | R4884
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License Number State | OR
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