Provider Demographics
NPI:1326497991
Name:WATERS, KELLI MARIE (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:WATERS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7360 WILLOW OAK DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3083
Mailing Address - Country:US
Mailing Address - Phone:248-420-1944
Mailing Address - Fax:
Practice Address - Street 1:30701 WOODWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0990
Practice Address - Country:US
Practice Address - Phone:586-753-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801099540104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker