Provider Demographics
NPI:1366710725
Name:WATERS, SHARON JOHNSON (CSC-AD)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:JOHNSON
Last Name:WATERS
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 WARWICK RD
Mailing Address - Street 2:
Mailing Address - City:EAST NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21631-1420
Mailing Address - Country:US
Mailing Address - Phone:410-943-8108
Mailing Address - Fax:
Practice Address - Street 1:3680 WARWICK RD
Practice Address - Street 2:
Practice Address - City:EAST NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21631-1420
Practice Address - Country:US
Practice Address - Phone:410-943-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1038101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD631501100Medicaid