Provider Demographics
NPI:1922884675
Name:WATERS, MARY ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WATERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 OWAHGENA TER
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-9631
Mailing Address - Country:US
Mailing Address - Phone:315-706-3386
Mailing Address - Fax:
Practice Address - Street 1:2 DEBBIE LN
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6759
Practice Address - Country:US
Practice Address - Phone:315-887-0221
Practice Address - Fax:315-216-4931
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY009837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist