Provider Demographics
NPI:1568866200
Name:WATERS, TRISHA (DT)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1505
Mailing Address - Country:US
Mailing Address - Phone:217-433-2704
Mailing Address - Fax:
Practice Address - Street 1:513 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1505
Practice Address - Country:US
Practice Address - Phone:217-433-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist