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General NPI Number Information
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NPI Number | 1992200901
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Entity Type | Organization
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Legal Business Name | SAFE WATERS MENTAL RECOVERY PLLC
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Dates
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Enumeration Date | 03/30/2018
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Last Update Date | 03/30/2018
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Provider Practice Location Address
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Address Line | 2101 N LAKEWOOD DR STE 226
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2473
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Country | US
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Telephone | 509-559-4720
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Fax |
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Provider Business Mailing Address
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Address Line | 2101 N LAKEWOOD DR STE 226
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2473
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Country | US
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Telephone | 509-559-4720
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KATHLEEN M SAMSEL
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Credential | LCSW
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Telephone | 509-599-4720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | W198609
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License Number State | ID
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