Provider Demographics
NPI:1912532961
Name:WATERS, COURTNEY LYNN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13809 LAMBETH RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:62685-6778
Mailing Address - Country:US
Mailing Address - Phone:217-710-7215
Mailing Address - Fax:
Practice Address - Street 1:1200 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-9600
Practice Address - Country:US
Practice Address - Phone:217-854-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant