Provider Demographics
NPI:1912948084
Name:WATERS, MICHAEL BRANDON (LPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRANDON
Last Name:WATERS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 OAK STREET EXTENSION
Mailing Address - Street 2:SUITE 145
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-3585
Mailing Address - Country:US
Mailing Address - Phone:828-245-5003
Mailing Address - Fax:828-245-5798
Practice Address - Street 1:247 OAK ST EXTENSION
Practice Address - Street 2:SUITE 145
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3585
Practice Address - Country:US
Practice Address - Phone:828-245-5003
Practice Address - Fax:828-245-5798
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017PXOtherBCBS
NC017PXOtherBCBS