Healthcare Provider Details

I. General information

NPI: 1942638960
Provider Name (Legal Business Name): KEITH D WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

IV. Provider business mailing address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-0602
  • Fax: 813-558-1343
Mailing address:
  • Phone: 813-974-0602
  • Fax: 813-558-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: