Provider Demographics
NPI:1093722811
Name:WATERS, MARY SUSAN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:WATERS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8596 E 101ST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7034
Mailing Address - Country:US
Mailing Address - Phone:918-671-2705
Mailing Address - Fax:918-369-7017
Practice Address - Street 1:8596 E 101ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7034
Practice Address - Country:US
Practice Address - Phone:918-671-2705
Practice Address - Fax:918-369-7017
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional