Provider Demographics
NPI:1922652783
Name:CAROLYN WATERSTRADT, PLLC
Entity Type:Organization
Organization Name:CAROLYN WATERSTRADT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERSTRADT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-903-8538
Mailing Address - Street 1:800 E ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5646
Mailing Address - Country:US
Mailing Address - Phone:231-799-4810
Mailing Address - Fax:
Practice Address - Street 1:800 E ELLIS RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5646
Practice Address - Country:US
Practice Address - Phone:231-799-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty