Provider Demographics
NPI:1255484580
Name:WATTERS, MELANIE GLASS (DPT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:GLASS
Last Name:WATTERS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 MONGWA OVI
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-3531
Mailing Address - Country:US
Mailing Address - Phone:205-531-5834
Mailing Address - Fax:
Practice Address - Street 1:2342 MONGWA OVI
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86005-3531
Practice Address - Country:US
Practice Address - Phone:205-531-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23143225100000X
ALPTH6021225100000X
AZPT10084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1255484580Medicare UPIN