MEDICARE: STILL WATERS RECOVERY COUNSELING AND WELLNESS

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1467819268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STILL WATERS RECOVERY COUNSELING AND WELLNESS

Provider Business Mailing Address
First Line	:	305 2ND AVE SE STE 200
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52401-1207
Country	:	US
Telephone Number	:	319-350-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 2ND AVE SE STE 200
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52401-1207
Country	:	US
Telephone Number	:	319-350-9444
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. KELLY GRANT MARSENGILL
Credential	:	CADC
Telephone Number	:	319-350-9444

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	02/24/2017

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