Provider Demographics
NPI:1548943905
Name:WATERS, KELLIE ANNE (LMSW)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANNE
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 TOOKER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1704
Mailing Address - Country:US
Mailing Address - Phone:610-763-0213
Mailing Address - Fax:
Practice Address - Street 1:42 TOOKER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1704
Practice Address - Country:US
Practice Address - Phone:610-763-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL069852001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical