Healthcare Provider Details

I. General information

NPI: 1831279421
Provider Name (Legal Business Name): PATRICK J. WATERS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 WRIGHTSBORO RD STE B
AUGUSTA GA
30904-4074
US

IV. Provider business mailing address

1727 WRIGHTSBORO RD SUITE B
AUGUSTA GA
30904
US

V. Phone/Fax

Practice location:
  • Phone: 706-736-8170
  • Fax: 706-736-8184
Mailing address:
  • Phone: 706-736-8170
  • Fax: 706-736-8184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW001501
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: