Healthcare Provider Details

I. General information

NPI: 1215717665
Provider Name (Legal Business Name): MRS. LATASHA WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CONCORD AVE STE 100
CONCORD CA
94520-4969
US

IV. Provider business mailing address

524 REPOSO ST SAN JACINT
SAN JACINTO CA
92582
US

V. Phone/Fax

Practice location:
  • Phone: 951-230-3034
  • Fax:
Mailing address:
  • Phone: 951-230-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-23-296530
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-296530
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: