1487723607 NPI number — MS. TRACY WATERS MSW, LCSW

Table of content: MS. TRACY WATERS MSW, LCSW (NPI 1487723607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487723607 NPI number — MS. TRACY WATERS MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
TRACY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ASSOCIATES
Provider Other First Name:
WEST END
Provider Other Middle Name:
COUNSELING
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487723607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST GROVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97116-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-359-1515
Provider Business Mailing Address Fax Number:
503-359-1433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2036 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116-2374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-359-1515
Provider Business Practice Location Address Fax Number:
503-359-1433
Provider Enumeration Date:
11/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  OR SWL 1361 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)