Provider Demographics
NPI:1053761270
Name:WATERS EDGE THERAPY, INC
Entity type:Organization
Organization Name:WATERS EDGE THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOWARD MORAND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-530-0880
Mailing Address - Street 1:127 WORTHING RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-3234
Mailing Address - Country:US
Mailing Address - Phone:207-530-0880
Mailing Address - Fax:
Practice Address - Street 1:127 WORTHING RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3234
Practice Address - Country:US
Practice Address - Phone:207-530-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health