Provider Demographics
NPI:1629255567
Name:WATERS, KIMBERLY SUE (MS-LLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MS-LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33493 W 14 MILE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1587
Mailing Address - Country:US
Mailing Address - Phone:248-851-5437
Mailing Address - Fax:248-592-1378
Practice Address - Street 1:33180 INDUSTRIAL RD STE 300
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-4200
Practice Address - Country:US
Practice Address - Phone:248-514-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical