=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346592748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERS & KAKLAMANOS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 10/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1664 METROPOLITAN CIR SUITE 2
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-7784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-385-1190
-----------------------------------------------------
Fax | 850-385-1191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1664 METROPOLITAN CIR SUITE 2
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-7784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-385-1190
-----------------------------------------------------
Fax | 850-385-1191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | DR. MARY WATERS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 850-385-1190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY 4135
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------