Healthcare Provider Details

I. General information

NPI: 1912817842
Provider Name (Legal Business Name): AUDREY WATERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W FAIRBANKS ST
MARQUETTE MI
49855-8915
US

IV. Provider business mailing address

129 W FAIRBANKS ST
MARQUETTE MI
49855-8915
US

V. Phone/Fax

Practice location:
  • Phone: 989-513-0538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851120199
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: