Basic Information
| Provider Information | |||||||||
| NPI: | 1770717043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERMAN | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4025 MARY LYNN DR | ||||||||
| Address2: | |||||||||
| City: | CANASTOTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130324736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157619689 | ||||||||
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| Practice Location | |||||||||
| Address1: | 138 N. COURT ST. | ||||||||
| Address2: | |||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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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 | 077801 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00569860 | 05 | NY | MEDICAID |