Provider Demographics
NPI:1740600360
Name:WATERS, DIANNA M (CMT)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:M
Last Name:WATERS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 THREE BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4422
Mailing Address - Country:US
Mailing Address - Phone:804-763-0267
Mailing Address - Fax:
Practice Address - Street 1:6500 HARBOUR VIEW CT
Practice Address - Street 2:SUIT 103
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2157
Practice Address - Country:US
Practice Address - Phone:804-763-0267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT69858643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist