Provider Demographics
NPI:1104842715
Name:WATERMAN, K. MELISSA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:K. MELISSA
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 NIAGARA RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-7767
Mailing Address - Country:US
Mailing Address - Phone:845-464-8910
Mailing Address - Fax:
Practice Address - Street 1:63 NIAGARA RD
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7767
Practice Address - Country:US
Practice Address - Phone:845-464-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR056648-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN576XMedicare ID - Type UnspecifiedPROVIDER NUMBER