MEDICARE: HEADWATER PSYCHOTHERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1447069091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEADWATER PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	1800 BRIDGEGATE ST STE 108
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-1468
Country	:	US
Telephone Number	:	805-405-6299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 BRIDGEGATE ST STE 108
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-1468
Country	:	US
Telephone Number	:	805-405-6299
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, LEAD CLINICIAN
Name	:	LANCE HOMER RACHELS
Credential	:	LMFT
Telephone Number	:	805-405-6299

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	12/10/2025

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