MEDICARE: DIANE MARIE WATERS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LCS 23656	CA

General Provider Information

NPI Number	:	1578775011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MARIE WATERS LCSW

Provider Business Mailing Address
First Line	:	4164 BROCKTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92501-3400
Country	:	US
Telephone Number	:	951-683-5193
Fax Number	:

Provider Business Practice Location Address
First Line	:	19322 JESSE LN
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-5072
Country	:	US
Telephone Number	:	951-387-4040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	06/19/2023

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