Provider Demographics
NPI:1760125918
Name:WATERMAN, KESHA DAVIS (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KESHA
Middle Name:DAVIS
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 BYRAM MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9301
Mailing Address - Country:US
Mailing Address - Phone:601-421-3041
Mailing Address - Fax:
Practice Address - Street 1:634 BYRAM MEADOWS DR
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9301
Practice Address - Country:US
Practice Address - Phone:601-421-3041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty