Provider Demographics
NPI:1891191805
Name:WATERMARK PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:WATERMARK PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZIO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:757-319-4650
Mailing Address - Street 1:821 W 21ST ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1500
Mailing Address - Country:US
Mailing Address - Phone:757-319-4650
Mailing Address - Fax:757-644-5065
Practice Address - Street 1:821 W 21ST ST
Practice Address - Street 2:SUITE 206
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1500
Practice Address - Country:US
Practice Address - Phone:757-319-4650
Practice Address - Fax:757-644-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005945101YP2500X
VA0810004778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty