Healthcare Provider Details

I. General information

NPI: 1598602013
Provider Name (Legal Business Name): MS. KATRINA WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 10026
DETROIT MI
48210-0026
US

IV. Provider business mailing address

9257 CASCADE ST
DETROIT MI
48204-1713
US

V. Phone/Fax

Practice location:
  • Phone: 313-344-6345
  • Fax:
Mailing address:
  • Phone: 313-344-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberW900000226165
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: