Healthcare Provider Details

I. General information

NPI: 1114881547
Provider Name (Legal Business Name): ALYSSA RENEE WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 CORPORATE DR
TROY MI
48098-2614
US

IV. Provider business mailing address

5505 CORPORATE DR
TROY MI
48098-2614
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-1210
  • Fax:
Mailing address:
  • Phone: 248-858-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851115922
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: