Provider Demographics
NPI:1356663900
Name:WATERS, LINDA MARIE (PCC)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:MARIE
Last Name:WATERS
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:MARIE
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICDC-CS
Mailing Address - Street 1:4307 WALNUT CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 E PERKINS AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7919
Practice Address - Country:US
Practice Address - Phone:419-357-3452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981033101YA0400X
OH0002689101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH981033OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD
OH0002689OtherOHIO COUNSELOR, SOCIAL WORKER, AND MARRIAGE AND FAMILY THERAPIST BOARD