Healthcare Provider Details

I. General information

NPI: 1548773120
Provider Name (Legal Business Name): CORINNE WATERS LCPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JUNE ST
SANFORD ME
04073-2621
US

IV. Provider business mailing address

70 ARI DR APT 312
WESTBROOK ME
04092-5025
US

V. Phone/Fax

Practice location:
  • Phone: 203-297-7576
  • Fax:
Mailing address:
  • Phone: 203-297-7576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL5578
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: