Provider Demographics
NPI:1386186096
Name:WATERS-MULLEN, CIARRA
Entity Type:Individual
Prefix:
First Name:CIARRA
Middle Name:
Last Name:WATERS-MULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 CONTI ST APT 3223
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5334
Mailing Address - Country:US
Mailing Address - Phone:510-717-0498
Mailing Address - Fax:
Practice Address - Street 1:3701 CONTI ST APT 3223
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5334
Practice Address - Country:US
Practice Address - Phone:510-717-0498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7583101YP2500X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA171M00000XMedicaid