Provider Demographics
NPI:1396243465
Name:FORD-WATERMAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FORD-WATERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20132 FORD ST.
Mailing Address - Street 2:
Mailing Address - City:LA FARGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1823
Practice Address - Country:US
Practice Address - Phone:315-771-7619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician