Healthcare Provider Details

I. General information

NPI: 1275965881
Provider Name (Legal Business Name): SUZANNA JOLENE WATERS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SUZANNA JOLENE REED

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 E GALA ST STE 100
MERIDIAN ID
83642-5210
US

IV. Provider business mailing address

3407 N RHONE PL
STAR ID
83669-5797
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-7333
  • Fax:
Mailing address:
  • Phone: 208-994-2607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-203922
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-6424
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: