Provider Demographics
NPI:1144570474
Name:WATERS, AMANDA JOY (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
Last Name:WATERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 HOCKANUM BLVD
Mailing Address - Street 2:UNIT 735
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-3096
Practice Address - Fax:310-223-0910
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical