=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871058099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STILL WATER SPRINGS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2019
-----------------------------------------------------
Last Update Date | 02/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 EAST AIRLINE ROAD SUITE 3
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-703-7103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 CALLE RICARDO
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77904-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-703-7103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY THERAPIST / OWNER
-----------------------------------------------------
Name | MR. AARON J MARINTEZ
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 361-703-7103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------