Provider Demographics
NPI:1700200656
Name:WATERS, SARA MARIE
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MARIE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-9741
Mailing Address - Country:US
Mailing Address - Phone:270-668-8349
Mailing Address - Fax:270-982-0829
Practice Address - Street 1:108 NEW GLENDALE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1023
Practice Address - Country:US
Practice Address - Phone:270-769-1601
Practice Address - Fax:270-982-0829
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000076961171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator