MEDICARE: WATERS & KAKLAMANOS, LLC

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	103TC0700X	Clinical Psychologist	PY4135	FL
2	103TC0700X	Clinical Psychologist	PY7401	FL

General Provider Information

NPI Number	:	1801154877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERS & KAKLAMANOS, LLC

Provider Business Mailing Address
First Line	:	1664-2 METROPOLITAN CIR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5413
Country	:	US
Telephone Number	:	850-528-8895
Fax Number	:	850-385-1191

Provider Business Practice Location Address
First Line	:	1664-2 METROPOLITAN CIRCLE
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5413
Country	:	US
Telephone Number	:	850-385-1190
Fax Number	:	850-385-1191

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST, MANAGER
Name	:	DR. KEELY WATERS KAKLAMANOS
Credential	:	PH.D.
Telephone Number	:	850-528-8895

Provider Enumeration Date	:	04/27/2012
Last Update Date	:	04/27/2012

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