Healthcare Provider Details

I. General information

NPI: 1053346908
Provider Name (Legal Business Name): WILLIAM FREDERICK WATERS PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 SUMMA AVE
BATON ROUGE LA
70809-3726
US

IV. Provider business mailing address

10310 THE GROVE BLVD
BATON ROUGE LA
70836-6455
US

V. Phone/Fax

Practice location:
  • Phone: 225-761-5200
  • Fax: 225-761-5512
Mailing address:
  • Phone: 225-761-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number347
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number347
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: