Provider Demographics
NPI:1104230945
Name:WATERS, DEMONSO
Entity type:Individual
Prefix:
First Name:DEMONSO
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 LANSDOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1218
Mailing Address - Country:US
Mailing Address - Phone:610-461-6510
Mailing Address - Fax:
Practice Address - Street 1:3915 ELSON RD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-1943
Practice Address - Country:US
Practice Address - Phone:610-505-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI002091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant