Basic Information
| Provider Information | |||||||||
| NPI: | 1780113126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | RACHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047815159 | ||||||||
| FaxNumber: | 3045238115 | ||||||||
| Practice Location | |||||||||
| Address1: | 3377 US ROUTE 60 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257052837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043993310 | ||||||||
| FaxNumber: | 3045235416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2287 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.