Provider Demographics
NPI:1447671359
Name:WATERS, KATHIE RAE (LCPC)
Entity type:Individual
Prefix:
First Name:KATHIE
Middle Name:RAE
Last Name:WATERS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:MT
Mailing Address - Zip Code:59538-0284
Mailing Address - Country:US
Mailing Address - Phone:406-654-1539
Mailing Address - Fax:
Practice Address - Street 1:47177 US HWY 2 WEST
Practice Address - Street 2:LOWER LEVEL SUITE 1
Practice Address - City:MALTA
Practice Address - State:MT
Practice Address - Zip Code:59538
Practice Address - Country:US
Practice Address - Phone:406-390-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT47-3779680OtherEIN