Provider Demographics
NPI:1285055376
Name:WATER'S EDGE PSYCHOTHERAPY AND WELLNESS CENTER
Entity type:Organization
Organization Name:WATER'S EDGE PSYCHOTHERAPY AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:206-963-4907
Mailing Address - Street 1:47 MAPLE ST STE 331
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5097
Mailing Address - Country:US
Mailing Address - Phone:206-963-4907
Mailing Address - Fax:802-861-0010
Practice Address - Street 1:47 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4861
Practice Address - Country:US
Practice Address - Phone:802-651-7807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006773Medicaid
VT1018888Medicaid
VT1285055376Medicaid
VT1018888Medicaid
VTVN2899Medicare PIN