Provider Demographics
NPI:1558427906
Name:WATERS-ROSE, KIMBERLY R (LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:R
Last Name:WATERS-ROSE
Suffix:
Gender:F
Credentials:LPC
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 408
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-0408
Mailing Address - Country:US
Mailing Address - Phone:678-947-9279
Mailing Address - Fax:678-947-9255
Practice Address - Street 1:2450 ATLANTA HWY STE 1403
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1277
Practice Address - Country:US
Practice Address - Phone:678-947-9279
Practice Address - Fax:678-947-9255
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional