Basic Information
| Provider Information | |||||||||
| NPI: | 1003296617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43882 | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212365564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438242815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9658 BALTIMORE AVE | ||||||||
| Address2: | #240 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207401346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438242815 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 04010 | MD | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.