Provider Demographics
NPI:1114309036
Name:WATERS, REBECCA ELLEN (CMT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA ELLEN
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MISS
Other - First Name:REBECCA ELLEN
Other - Middle Name:
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:7807 W SALLY CT
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9869
Mailing Address - Country:US
Mailing Address - Phone:907-357-0143
Mailing Address - Fax:
Practice Address - Street 1:7807 W SALLY CT
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-9869
Practice Address - Country:US
Practice Address - Phone:907-357-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist