Provider Demographics
NPI:1184483703
Name:WATERS, ANGELA (LMHCA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 ARDMORE AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-4863
Mailing Address - Country:US
Mailing Address - Phone:949-525-8414
Mailing Address - Fax:
Practice Address - Street 1:4150 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1208
Practice Address - Country:US
Practice Address - Phone:260-702-3759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001696A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health