Provider Demographics
NPI:1780158030
Name:WATERS-ROMAN, DEBRA KAY (LCP)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:KAY
Last Name:WATERS-ROMAN
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 THORNHURST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2364
Mailing Address - Country:US
Mailing Address - Phone:626-482-7017
Mailing Address - Fax:
Practice Address - Street 1:17814 WOODRUFF AVE STE 3
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-7000
Practice Address - Country:US
Practice Address - Phone:714-585-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27444103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling