Provider Demographics
NPI:1235899196
Name:WATERS, SYDNEE SUE
Entity Type:Individual
Prefix:MRS
First Name:SYDNEE
Middle Name:SUE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SYDNEE
Other - Middle Name:SUE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1234 W CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1818
Mailing Address - Country:US
Mailing Address - Phone:989-339-0018
Mailing Address - Fax:
Practice Address - Street 1:2231 BERT RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-8602
Practice Address - Country:US
Practice Address - Phone:989-339-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0021343978Medicaid