Provider Demographics
NPI:1154526846
Name:WATERS, TYRONE WAYNE (PEER ADVOCATE LEAD)
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:WAYNE
Last Name:WATERS
Suffix:
Gender:M
Credentials:PEER ADVOCATE LEAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MORRIS ST
Mailing Address - Street 2:#315
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1572
Mailing Address - Country:US
Mailing Address - Phone:503-238-6801
Mailing Address - Fax:
Practice Address - Street 1:2034 SE 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4510
Practice Address - Country:US
Practice Address - Phone:503-238-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health