Provider Demographics
NPI:1134717085
Name:WATERS, GLENDA S (RN, LMBT)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:S
Last Name:WATERS
Suffix:
Gender:F
Credentials:RN, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 COUNTRY MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-7783
Mailing Address - Country:US
Mailing Address - Phone:704-473-4720
Mailing Address - Fax:
Practice Address - Street 1:110 W KING ST STE 2
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3437
Practice Address - Country:US
Practice Address - Phone:704-739-3373
Practice Address - Fax:704-739-3918
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02832225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist