Provider Demographics
NPI:1720081045
Name:WATERS, LINDA G (PHD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:G
Last Name:WATERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 VAN NUYS BLVD.
Mailing Address - Street 2:#302
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-990-4497
Mailing Address - Fax:818-990-6045
Practice Address - Street 1:4940 VAN NUYS BL.
Practice Address - Street 2:#302
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-990-4497
Practice Address - Fax:818-990-6045
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5465103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5465Medicare UPIN