Provider Demographics
NPI:1215946041
Name:WATTERS, RENEE LYNN
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:LYNN
Last Name:WATTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:LYNN
Other - Last Name:KORBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6791 OLD WATERLOO RD APT 718
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7185
Mailing Address - Country:US
Mailing Address - Phone:218-791-7662
Mailing Address - Fax:
Practice Address - Street 1:611 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3801
Practice Address - Country:US
Practice Address - Phone:410-328-2293
Practice Address - Fax:410-328-5895
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical