Provider Demographics
NPI:1487805537
Name:WATERLEAF
Entity type:Organization
Organization Name:WATERLEAF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:LEEMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, ACSW
Authorized Official - Phone:269-449-7809
Mailing Address - Street 1:815 MAIN ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1473
Mailing Address - Country:US
Mailing Address - Phone:269-982-4055
Mailing Address - Fax:219-462-9000
Practice Address - Street 1:4004 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-1773
Practice Address - Country:US
Practice Address - Phone:219-462-9000
Practice Address - Fax:219-462-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty