| Living Waters Therapeutic Alliance Inc | |
|
2570 River Watch Dr Suffolk VA 23434-8669 | |
| (757) 270-3976 | |
| Not Available |
| Full Name | Living Waters Therapeutic Alliance Inc |
|---|---|
| Speciality | Counselor |
| Location | 2570 River Watch Dr, Suffolk, Virginia |
| Authorized Official Name and Position | Charlena Judith Catherine Correll (DIRECTOR) |
| Authorized Official Contact | 7574057519 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Living Waters Therapeutic Alliance Inc 2570 River Watch Dr Suffolk VA 23434-8669 Ph: (757) 270-3976 | Living Waters Therapeutic Alliance Inc 2570 River Watch Dr Suffolk VA 23434-8669 Ph: (757) 270-3976 |
| NPI Number | 1174207609 |
|---|---|
| Provider Enumeration Date | 06/14/2023 |
| Last Update Date | 12/02/2024 |
| Certification Date | 12/02/2024 |
| Medicare PECOS PAC ID | 9234592486 |
|---|---|
| Medicare Enrollment ID | O20241203000821 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1174207609 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Charlena Judith Catherine Correll |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1609531615 PECOS PAC ID: 8325401573 Enrollment ID: I20241203000986 |
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