Provider Demographics
NPI:1902201494
Name:WATERS, JUSTIN DANIEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:WATERS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WILDWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:NY
Mailing Address - Zip Code:13340-9109
Mailing Address - Country:US
Mailing Address - Phone:315-790-2893
Mailing Address - Fax:
Practice Address - Street 1:1500 N JAMES ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2844
Practice Address - Country:US
Practice Address - Phone:315-337-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038105225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist