Healthcare Provider Details

I. General information

NPI: 1740636745
Provider Name (Legal Business Name): MARK O WATERS LPC, CAADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ARBOR LN
ALPENA MI
49707-1302
US

IV. Provider business mailing address

112 ARBOR LN
ALPENA MI
49707-1302
US

V. Phone/Fax

Practice location:
  • Phone: 989-340-2131
  • Fax: 989-340-2168
Mailing address:
  • Phone: 989-340-2131
  • Fax: 989-340-2168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-03793
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: