Provider Demographics
NPI:1407639636
Name:WATERMAN, CODY (ADT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BROADWAY ST STE 110
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-6760
Mailing Address - Country:US
Mailing Address - Phone:301-637-0222
Mailing Address - Fax:
Practice Address - Street 1:205 BROADWAY ST STE 110
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6760
Practice Address - Country:US
Practice Address - Phone:301-637-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT3307101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)