Provider Demographics
NPI:1366629164
Name:WATTERS, MARCIA (PTA)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:WATTERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PATTI CT
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1421
Mailing Address - Country:US
Mailing Address - Phone:618-282-2183
Mailing Address - Fax:
Practice Address - Street 1:434 N WEST ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1359
Practice Address - Country:US
Practice Address - Phone:573-547-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116285225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO116285OtherSTATE OF MISSOURI