Basic Information
| Provider Information | |||||||||
| NPI: | 1366562720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 RAY C HUNT DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229032981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349806140 | ||||||||
| FaxNumber: | 4349724266 | ||||||||
| Practice Location | |||||||||
| Address1: | 1ST LEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349241613 | ||||||||
| FaxNumber: | 4349824306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810000760 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 007755643 | 05 | VA | MEDICAID |