Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 2012018184 | MO |
NPI | 1003236522 |
---|---|
Provider Name | Angela Waterman |
First Address | Ash Grove, MO 65604-7187 |
Second Address | Ash Grove, MO 65604-7187 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2014 |
Last Update Date | 23/04/2014 |