Provider Demographics
NPI:1487907168
Name:WATERMAN, ELIZABETH WILLIS (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:WILLIS
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12236 ASHLEY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2759
Mailing Address - Country:US
Mailing Address - Phone:228-539-2205
Mailing Address - Fax:228-539-2205
Practice Address - Street 1:12236 ASHLEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2759
Practice Address - Country:US
Practice Address - Phone:228-539-2205
Practice Address - Fax:228-539-2205
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC59491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical