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General NPI Number Information
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NPI Number | 1811450646
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Entity Type | Organization
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Legal Business Name | LIVING WATERS PEACE CENTER
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Dates
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Enumeration Date | 04/09/2019
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Last Update Date | 04/09/2019
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Provider Practice Location Address
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Address Line | 3262 MALLARD COVE LN STE B
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City | FORT WAYNE
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State | IN
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Zip | 46804-2883
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Country | US
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Telephone | 260-230-1180
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Fax |
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Provider Business Mailing Address
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Address Line | 3262 MALLARD COVE LN STE B
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City | FORT WAYNE
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State | IN
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Zip | 46804-2883
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Country | US
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Telephone | 260-230-1180
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Fax |
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Authorized Official
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Title or Position | OWNER/MENTAL HEALTH COUNSELOR ASSOC
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Name | MRS. TRACY LYNN CAIN
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Credential | LMHCA
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Telephone | 260-230-1180
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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 |
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License Number State |
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