Provider Demographics
NPI:1770717043
Name:WATERMAN, JULIE A (LCSW)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 MARY LYNN DR
Mailing Address - Street 2:
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-4736
Mailing Address - Country:US
Mailing Address - Phone:315-761-9689
Mailing Address - Fax:
Practice Address - Street 1:138 N. COURT ST.
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077801101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569860Medicaid
NY536220Medicare PIN