Provider Demographics
NPI:1922740349
Name:WATERS, TIARA E (LMT)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:E
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 NOB HILL RD APT A
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3239
Mailing Address - Country:US
Mailing Address - Phone:860-705-2138
Mailing Address - Fax:
Practice Address - Street 1:20 NOB HILL RD APT A
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-3239
Practice Address - Country:US
Practice Address - Phone:860-705-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10354225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336078OtherSTATE