Basic Information
| Provider Information | |||||||||
| NPI: | 1902937451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | KATHYE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749689660 | ||||||||
| FaxNumber: | 5742460171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 LINCOLNWAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742562255 | ||||||||
| FaxNumber: | 5742460171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 03/19/2010 | ||||||||
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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 | 101YM0800X | 39001162A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.