Basic Information
| Provider Information | |||||||||
| NPI: | 1336797596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | HALEY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 217 PINE LOG RD | ||||||||
| Address2: | |||||||||
| City: | BEECH ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298428308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068404032 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 916 REYNOLDS RD | ||||||||
| Address2: | |||||||||
| City: | BARNWELL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298126358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032597170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2019 | ||||||||
| LastUpdateDate: | 08/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.