Provider Demographics
NPI:1871996918
Name:WATERSTRADT, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WATERSTRADT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E ELLIS RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5646
Practice Address - Country:US
Practice Address - Phone:231-799-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02753101YA0400X
MI68010942451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)