Basic Information
| Provider Information | |||||||||
| NPI: | 1003017740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHS CSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCNALLY | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 177 WILD OAKS DR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080793350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568789011 | ||||||||
| FaxNumber: | 8568789012 | ||||||||
| Practice Location | |||||||||
| Address1: | 1868 GREENTREE ROAD | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564244408 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 44SW00345300 | NJ | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.