Provider Demographics
NPI:1861901464
Name:WATERS, KATRINA KENNEDY (MACCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:KENNEDY
Last Name:WATERS
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4791 NW 69TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-7622
Mailing Address - Country:US
Mailing Address - Phone:352-804-3348
Mailing Address - Fax:
Practice Address - Street 1:521 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-7034
Practice Address - Country:US
Practice Address - Phone:352-401-7916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist