Provider Demographics
NPI:1447069091
Name:HEADWATER PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:HEADWATER PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:HOMER
Authorized Official - Last Name:RACHELS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:805-405-6299
Mailing Address - Street 1:1684 WELLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1535
Mailing Address - Country:US
Mailing Address - Phone:805-469-0469
Mailing Address - Fax:
Practice Address - Street 1:1800 BRIDGEGATE ST STE 108
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-1468
Practice Address - Country:US
Practice Address - Phone:805-405-6299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health