Provider Demographics
NPI:1396861803
Name:WATERS, MARY SCIENZO (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SCIENZO
Last Name:WATERS
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 1:29 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-2113
Mailing Address - Country:US
Mailing Address - Phone:508-759-9438
Mailing Address - Fax:
Practice Address - Street 1:8 LEWIS POINT RD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-5613
Practice Address - Country:US
Practice Address - Phone:508-743-8120
Practice Address - Fax:508-759-3628
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2470225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant