Provider Demographics
NPI:1093201378
Name:WATERS, KATHERINE LORRAINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LORRAINE
Last Name:WATERS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LORRAINE
Other - Last Name:HALTIWANGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1331 CONNECTICUT ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3223
Mailing Address - Country:US
Mailing Address - Phone:619-930-9750
Mailing Address - Fax:
Practice Address - Street 1:3704 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1812
Practice Address - Country:US
Practice Address - Phone:619-930-9750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA294964OtherPT LICENSE NUMBER