Provider Demographics
NPI:1275810384
Name:WATERMAN, BRIAN T (CDP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15455 65TH AVE S
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2534
Mailing Address - Country:US
Mailing Address - Phone:206-721-5170
Mailing Address - Fax:206-721-6288
Practice Address - Street 1:15455 65TH AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2534
Practice Address - Country:US
Practice Address - Phone:206-721-5170
Practice Address - Fax:206-721-6288
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003772101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)