Provider Demographics
NPI:1457478877
Name:TINA E WATERS LCSW LLC
Entity Type:Organization
Organization Name:TINA E WATERS LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:908-203-9054
Mailing Address - Street 1:131 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2108
Mailing Address - Country:US
Mailing Address - Phone:908-203-9054
Mailing Address - Fax:
Practice Address - Street 1:131 W HIGH ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2108
Practice Address - Country:US
Practice Address - Phone:908-203-9054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC045739001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ017153Medicare ID - Type Unspecified