Provider Demographics
NPI:1568877785
Name:WATERS, JOHNNY (MHC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7266 BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2649
Mailing Address - Country:US
Mailing Address - Phone:315-458-0919
Mailing Address - Fax:315-458-0954
Practice Address - Street 1:7266 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2649
Practice Address - Country:US
Practice Address - Phone:315-458-0919
Practice Address - Fax:315-458-0954
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)