Provider Demographics
NPI:1114721032
Name:WATERS, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:WATERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N BAILEY CIR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1276
Mailing Address - Country:US
Mailing Address - Phone:231-409-3256
Mailing Address - Fax:
Practice Address - Street 1:2157 UNIVERSITY PARK DR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5956
Practice Address - Country:US
Practice Address - Phone:517-243-9738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511164301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical