Provider Demographics
NPI:1467706747
Name:WATERS, BOBBI JEAN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:BOBBI
Middle Name:JEAN
Last Name:WATERS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55929-1415
Mailing Address - Country:US
Mailing Address - Phone:715-797-8702
Mailing Address - Fax:
Practice Address - Street 1:327 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:MN
Practice Address - Zip Code:55929-1415
Practice Address - Country:US
Practice Address - Phone:715-797-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-12-11583103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst