Provider Demographics
NPI:1285736348
Name:WATTERS, MALISSA A (LCSW)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:A
Last Name:WATTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:A
Other - Last Name:KEPNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:866 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-5454
Mailing Address - Country:US
Mailing Address - Phone:815-935-0688
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490110201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical