Provider Demographics
NPI:1669559464
Name:WATERS, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 SOUTH RANGE
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-2931
Mailing Address - Country:US
Mailing Address - Phone:785-460-6586
Mailing Address - Fax:785-586-2356
Practice Address - Street 1:175 SOUTH RANGE
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:KS
Practice Address - Zip Code:67701-2931
Practice Address - Country:US
Practice Address - Phone:785-462-3332
Practice Address - Fax:785-462-3337
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS529101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)