Provider Demographics
NPI:1164705000
Name:WATERHOUSE, COLEEN LYNN
Entity Type:Individual
Prefix:MRS
First Name:COLEEN
Middle Name:LYNN
Last Name:WATERHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:COLEEN
Other - Middle Name:LYNN
Other - Last Name:MOSHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 HARRIS RD.
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:NY
Mailing Address - Zip Code:12827
Mailing Address - Country:US
Mailing Address - Phone:518-654-6424
Mailing Address - Fax:
Practice Address - Street 1:311 HARRIS RD.
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:NY
Practice Address - Zip Code:12827
Practice Address - Country:US
Practice Address - Phone:518-654-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004670-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist