Provider Demographics
NPI:1205256211
Name:WATERFORD ACADEMY LLC
Entity type:Organization
Organization Name:WATERFORD ACADEMY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-365-5318
Mailing Address - Street 1:1033 LONG PRAIRIE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4230
Mailing Address - Country:US
Mailing Address - Phone:972-355-9083
Mailing Address - Fax:
Practice Address - Street 1:1033 LONG PRAIRIE RD STE 3
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4230
Practice Address - Country:US
Practice Address - Phone:972-355-9083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty