Provider Demographics
NPI:1275965881
Name:WATERS, SUZANNA JOLENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNA
Middle Name:JOLENE
Last Name:WATERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:SUZANNA
Other - Middle Name:JOLENE
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3407 N RHONE PL
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5797
Mailing Address - Country:US
Mailing Address - Phone:208-994-2607
Mailing Address - Fax:
Practice Address - Street 1:2463 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5210
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203922103TC0700X
IDLCPC-6424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional