Provider Demographics
NPI:1710616172
Name:WATHEN, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WATHEN
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 1:3321 CAMDEN HWY
Mailing Address - Street 2:
Mailing Address - City:DALZELL
Mailing Address - State:SC
Mailing Address - Zip Code:29040-8995
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3321 CAMDEN HWY
Practice Address - Street 2:
Practice Address - City:DALZELL
Practice Address - State:SC
Practice Address - Zip Code:29040-8995
Practice Address - Country:US
Practice Address - Phone:302-747-8403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5198224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant