Provider Demographics
NPI:1487723607
Name:WATERS, TRACY (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:WEST END
Other - Middle Name:COUNSELING
Other - Last Name:ASSOCIATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0428
Mailing Address - Country:US
Mailing Address - Phone:503-359-1515
Mailing Address - Fax:503-359-1433
Practice Address - Street 1:2036 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2374
Practice Address - Country:US
Practice Address - Phone:503-359-1515
Practice Address - Fax:503-359-1433
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR SWL 13611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107872Medicare ID - Type Unspecified