Provider Demographics
NPI:1245380971
Name:WATFORD, AMBER MARISA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MARISA
Last Name:WATFORD
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MARISA
Other - Last Name:MOURING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:329 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10301 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-604-6913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 2802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer