Provider Demographics
NPI:1457927485
Name:WATERS, TYSHON (LPC, CPRP)
Entity Type:Individual
Prefix:
First Name:TYSHON
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:LPC, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 EVANS DR UNIT 456
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-2710
Mailing Address - Country:US
Mailing Address - Phone:678-670-1816
Mailing Address - Fax:
Practice Address - Street 1:1811 SAINT IVES XING
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9011
Practice Address - Country:US
Practice Address - Phone:678-670-1816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012109101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty