Provider Demographics
NPI:1083917645
Name:WATERS, MARY FAITH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:FAITH
Last Name:WATERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:385 TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1023
Mailing Address - Country:US
Mailing Address - Phone:201-270-9413
Mailing Address - Fax:
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:201-270-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC04573800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker