Provider Demographics
NPI:1114001625
Name:WATERS, GREG A (PT)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:A
Last Name:WATERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S 1ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-2005
Mailing Address - Country:US
Mailing Address - Phone:509-697-5330
Mailing Address - Fax:509-697-5355
Practice Address - Street 1:304 S 1ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-2005
Practice Address - Country:US
Practice Address - Phone:509-697-5330
Practice Address - Fax:509-697-5355
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0290142OtherLABOR & INDUSTRIES