Provider Demographics
NPI:1891183216
Name:WATERMAN, JOHN M (CASAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:657 S COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:E PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5550
Mailing Address - Country:US
Mailing Address - Phone:631-371-2680
Mailing Address - Fax:631-702-8050
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-363-2001
Practice Address - Fax:631-702-8050
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25901101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)