Provider Demographics
NPI:1730837899
Name:CUP OF COOL WATER
Entity type:Organization
Organization Name:CUP OF COOL WATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:WALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-747-6686
Mailing Address - Street 1:1106 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-4506
Mailing Address - Country:US
Mailing Address - Phone:509-747-6686
Mailing Address - Fax:
Practice Address - Street 1:1106 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4506
Practice Address - Country:US
Practice Address - Phone:509-747-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty