Provider Demographics
NPI:1750769667
Name:WATERS, CRISTY
Entity type:Individual
Prefix:
First Name:CRISTY
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6313 NW 46TH STREET
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73122
Mailing Address - Country:US
Mailing Address - Phone:770-715-5676
Mailing Address - Fax:
Practice Address - Street 1:6313 NW 46TH ST
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73122-4005
Practice Address - Country:US
Practice Address - Phone:770-715-5676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200423650AMedicaid