Provider Demographics
NPI:1750500153
Name:WATERS, SUSAN EMILY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:EMILY
Last Name:WATERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 FAIR OAKS AVE
Mailing Address - Street 2:# 214
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3311
Mailing Address - Country:US
Mailing Address - Phone:310-892-1240
Mailing Address - Fax:
Practice Address - Street 1:1460 WESTWOOD BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4975
Practice Address - Country:US
Practice Address - Phone:310-892-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS150251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical