Provider Demographics
NPI:1790923530
Name:WATERS, ABIGAIL A (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:A
Last Name:WATERS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5803 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4108
Mailing Address - Country:US
Mailing Address - Phone:262-945-4506
Mailing Address - Fax:
Practice Address - Street 1:311 W DEPOT ST
Practice Address - Street 2:SUITE N
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1500
Practice Address - Country:US
Practice Address - Phone:847-838-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant