Provider Demographics
NPI:1306945225
Name:WATERS, ELLEN KOSSE (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:KOSSE
Last Name:WATERS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 AYER RD
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:MA
Mailing Address - Zip Code:01451-1108
Mailing Address - Country:US
Mailing Address - Phone:978-772-4457
Mailing Address - Fax:978-772-7107
Practice Address - Street 1:257 AYER ROAD
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:MA
Practice Address - Zip Code:01451
Practice Address - Country:US
Practice Address - Phone:978-772-4457
Practice Address - Fax:978-772-7107
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1029721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P30049Medicare ID - Type Unspecified