Provider Demographics
NPI:1891757993
Name:WATERS, GWYNNE FORREST (DPT)
Entity Type:Individual
Prefix:MRS
First Name:GWYNNE
Middle Name:FORREST
Last Name:WATERS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:281 ENTERPRISE CT STE 200
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0311
Practice Address - Country:US
Practice Address - Phone:248-322-5280
Practice Address - Fax:248-333-1915
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist