Provider Demographics
NPI:1528381373
Name:WATERS, MARYBETH NOLAN (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:NOLAN
Last Name:WATERS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:MOSS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:94038-0036
Mailing Address - Country:US
Mailing Address - Phone:650-924-3342
Mailing Address - Fax:650-728-7695
Practice Address - Street 1:625 MIRAMONTES ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1942
Practice Address - Country:US
Practice Address - Phone:650-924-3342
Practice Address - Fax:650-728-7695
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44841106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist