Provider Demographics
NPI:1861731440
Name:WATERS, ADAM (MFT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 VIA MARINA APT 817
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6896
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1714 21ST ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3917
Practice Address - Country:US
Practice Address - Phone:310-829-7391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32988106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist