MEDICARE: MS. KIMBERLY R. WATERS-ROSE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	003197	GA

General Provider Information

NPI Number	:	1558427906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY R. WATERS-ROSE LPC

Provider Business Mailing Address
First Line	:	PO BOX 408
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30028-0408
Country	:	US
Telephone Number	:	678-947-9279
Fax Number	:	678-947-9255

Provider Business Practice Location Address
First Line	:	2450 ATLANTA HWY STE 1403
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-1277
Country	:	US
Telephone Number	:	678-947-9279
Fax Number	:	678-947-9255

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	03/07/2022

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