Provider Demographics
NPI:1952921116
Name:WATERMAN, NICHOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:WATERMAN
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 1:101 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-2879
Mailing Address - Country:US
Mailing Address - Phone:712-254-9018
Mailing Address - Fax:712-254-9019
Practice Address - Street 1:101 E 22ND ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-2879
Practice Address - Country:US
Practice Address - Phone:712-254-9018
Practice Address - Fax:712-254-9019
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health