MEDICARE: THERESA LATISHA WATERS

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	1041C0700X	Clinical Social Worker	150.112384	IL
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1851074108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA LATISHA WATERS

Provider Business Mailing Address
First Line	:	25 N PARKSIDE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 N PARKSIDE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3904
Country	:	US
Telephone Number	:	773-939-2484
Fax Number	:

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

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	12/10/2025

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Directions to “ THERESA LATISHA WATERS ” Practice Location

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