Provider Demographics
NPI:1629385224
Name:WATERS, RICHARD STEPHEN (PSY D)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:STEPHEN
Last Name:WATERS
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:508-532-2200
Mailing Address - Fax:508-853-8593
Practice Address - Street 1:650 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2060
Practice Address - Country:US
Practice Address - Phone:508-595-0750
Practice Address - Fax:508-595-1130
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MA10058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XMedicaid