Provider Demographics
NPI:1548721699
Name:WATERS, SAMUEL J (BS)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:WATERS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N50796 COUNTY ROAD O
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:WI
Mailing Address - Zip Code:54758-6601
Mailing Address - Country:US
Mailing Address - Phone:715-864-0674
Mailing Address - Fax:
Practice Address - Street 1:2620 STEIN BLVD STE B
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2674
Practice Address - Country:US
Practice Address - Phone:715-458-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst