Healthcare Provider Details

I. General information

NPI: 1669559464
Provider Name (Legal Business Name): FRED WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 SOUTH RANGE
COLBY KS
67701-2931
US

IV. Provider business mailing address

175 SOUTH RANGE
COLBY KS
67701-2931
US

V. Phone/Fax

Practice location:
  • Phone: 785-462-3332
  • Fax: 785-462-3337
Mailing address:
  • Phone: 785-460-6586
  • Fax: 785-586-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number529
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number529
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: