Provider Demographics
NPI:1205534575
Name:WATERMAN, OLIVIA L (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:L
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 WINDSTREAM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-1060
Mailing Address - Country:US
Mailing Address - Phone:512-909-5220
Mailing Address - Fax:
Practice Address - Street 1:1302 WINDSTREAM ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76209-1060
Practice Address - Country:US
Practice Address - Phone:512-909-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
TXAT93162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer