Provider Demographics
NPI:1861017196
Name:WATERS, JOHN S
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STELLA CT # 221
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1011
Mailing Address - Country:US
Mailing Address - Phone:614-252-8402
Mailing Address - Fax:614-252-7987
Practice Address - Street 1:2100 STELLA CT # 221
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1011
Practice Address - Country:US
Practice Address - Phone:614-252-8402
Practice Address - Fax:614-252-7987
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0020988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker