Provider Demographics
NPI:1093861916
Name:WATERS, SHANNON MARIE (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21111 NALL AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:KS
Mailing Address - Zip Code:66013-9502
Mailing Address - Country:US
Mailing Address - Phone:913-548-1958
Mailing Address - Fax:
Practice Address - Street 1:503 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1502
Practice Address - Country:US
Practice Address - Phone:816-252-8388
Practice Address - Fax:816-252-1337
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist