Provider Demographics
NPI:1174074447
Name:WATERS, CHY
Entity type:Individual
Prefix:
First Name:CHY
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:WAURIKA
Mailing Address - State:OK
Mailing Address - Zip Code:73573
Mailing Address - Country:US
Mailing Address - Phone:580-313-0298
Mailing Address - Fax:
Practice Address - Street 1:1114 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:WAURIKA
Practice Address - State:OK
Practice Address - Zip Code:73573-1414
Practice Address - Country:US
Practice Address - Phone:580-313-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool