Basic Information
| Provider Information | |||||||||
| NPI: | 1548421050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 BELLVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405420200 | ||||||||
| FaxNumber: | 5405420318 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 GRAFTON LANE | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405420200 | ||||||||
| FaxNumber: | 5405420318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC50077982 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LC50077982 | 01 | VA | LICENSE FOR IND CLINICAL SOCIAL WORKER | OTHER |