Provider Demographics
NPI:1265655260
Name:WATERS, ALISSA MICHELE
Entity Type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:MICHELE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43273 335TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRIGGSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62340-2312
Mailing Address - Country:US
Mailing Address - Phone:217-833-2898
Mailing Address - Fax:217-833-2898
Practice Address - Street 1:43273 335TH AVE
Practice Address - Street 2:
Practice Address - City:GRIGGSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62340-2312
Practice Address - Country:US
Practice Address - Phone:217-833-2898
Practice Address - Fax:217-833-2898
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist