Provider Demographics
NPI:1972074391
Name:WATERMAN, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 TIDLER CT
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9111
Mailing Address - Country:US
Mailing Address - Phone:443-500-0204
Mailing Address - Fax:
Practice Address - Street 1:516 N ROLLING RD STE 305
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4142
Practice Address - Country:US
Practice Address - Phone:443-500-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMT2399225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty