Provider Demographics
NPI:1124378575
Name:WATERS, KRISTINE (LMFT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 JOSEPHINE RD
Mailing Address - Street 2:
Mailing Address - City:STAMPING GROUND
Mailing Address - State:KY
Mailing Address - Zip Code:40379-9687
Mailing Address - Country:US
Mailing Address - Phone:502-320-7175
Mailing Address - Fax:
Practice Address - Street 1:1236 PARIS PIKE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9701
Practice Address - Country:US
Practice Address - Phone:502-320-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0779106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid