Provider Demographics
NPI:1285310482
Name:WATERS, IVON L (PCLC)
Entity type:Individual
Prefix:
First Name:IVON
Middle Name:L
Last Name:WATERS
Suffix:
Gender:M
Credentials:PCLC
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:L
Other - Last Name:WODARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:81 TREASURE STATE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 TREASURE STATE DR
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-3454
Practice Address - Country:US
Practice Address - Phone:406-402-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-44130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional