Provider Demographics
NPI:1922048826
Name:WATERS, EUGENE CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:CHARLES
Last Name:WATERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 S 61ST ST
Mailing Address - Street 2:STE 126
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-6817
Mailing Address - Country:US
Mailing Address - Phone:254-493-4559
Mailing Address - Fax:
Practice Address - Street 1:2027 S 61ST ST
Practice Address - Street 2:STE 126
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6817
Practice Address - Country:US
Practice Address - Phone:254-774-8272
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21344103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115345401Medicaid
742517797Medicare UPIN
TX115345401Medicaid