Provider Demographics
NPI:1720670771
Name:WATERS, BRIAN (ACSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2639
Mailing Address - Country:US
Mailing Address - Phone:845-913-6414
Mailing Address - Fax:
Practice Address - Street 1:341 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-1402
Practice Address - Country:US
Practice Address - Phone:562-435-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health