Provider Demographics
NPI:1740404011
Name:WATERS, SUSAN K (SOCIAL WORKER)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:WATERS
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#16 COUNTY ROAD 1499
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:NM
Mailing Address - Zip Code:87418
Mailing Address - Country:US
Mailing Address - Phone:505-947-8819
Mailing Address - Fax:
Practice Address - Street 1:501 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2652
Practice Address - Country:US
Practice Address - Phone:505-325-2778
Practice Address - Fax:505-325-6171
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 057261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical