Provider Demographics
NPI:1609590801
Name:WATERMAN, ERIC ANDREW
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ANDREW
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 BAYFORD CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-6217
Mailing Address - Country:US
Mailing Address - Phone:757-870-6672
Mailing Address - Fax:
Practice Address - Street 1:4104 BAYFORD CT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-6217
Practice Address - Country:US
Practice Address - Phone:757-870-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-22-236981106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician