Healthcare Provider Details

I. General information

NPI: 1275116261
Provider Name (Legal Business Name): TERRELL A WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 01/18/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

IV. Provider business mailing address

525 S 4TH ST STE 471
PHILADELPHIA PA
19147-1582
US

V. Phone/Fax

Practice location:
  • Phone: 267-861-3685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMC61510465
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: