Provider Demographics
NPI:1538901905
Name:LANE-WATERS, KATIE LOUISE (LLMSW)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LOUISE
Last Name:LANE-WATERS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N NORMAL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3316
Mailing Address - Country:US
Mailing Address - Phone:248-602-1640
Mailing Address - Fax:
Practice Address - Street 1:271 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1637
Practice Address - Country:US
Practice Address - Phone:248-216-5781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851118121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker