Basic Information
| Provider Information | |||||||||
| NPI: | 1013322965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LEACIE WILSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267445230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2550 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267445230 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2014 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 103T00000X | 31585 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.