Provider Demographics
NPI:1023598927
Name:WATERS, SHANNON FAYE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:FAYE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RHODE ISLAND AVE NE APT 126A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-6806
Mailing Address - Country:US
Mailing Address - Phone:830-387-8881
Mailing Address - Fax:
Practice Address - Street 1:101 T ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1519
Practice Address - Country:US
Practice Address - Phone:202-724-4223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool