Provider Demographics
NPI:1962164723
Name:WATTERS, VIVIAN E
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:E
Last Name:WATTERS
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 1:303 S RECKER RD LOT 47
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6077
Mailing Address - Country:US
Mailing Address - Phone:480-295-5600
Mailing Address - Fax:
Practice Address - Street 1:303 S RECKER RD LOT 47
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6077
Practice Address - Country:US
Practice Address - Phone:480-295-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW6921T104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty