Provider Demographics
NPI:1033514005
Name:WAITS, KATHRYN LEIGH (LMT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEIGH
Last Name:WAITS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:LEIGH
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2208 W WILLOW KNOLLS RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1467
Mailing Address - Country:US
Mailing Address - Phone:309-693-9600
Mailing Address - Fax:309-693-3616
Practice Address - Street 1:2208 W WILLOW KNOLLS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1467
Practice Address - Country:US
Practice Address - Phone:309-693-9600
Practice Address - Fax:309-693-3616
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227014994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist