Provider Demographics
NPI:1528157385
Name:WATERS, SEAN W (MS,PT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:W
Last Name:WATERS
Suffix:
Gender:M
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0101
Mailing Address - Country:US
Mailing Address - Phone:833-888-7868
Mailing Address - Fax:833-888-7868
Practice Address - Street 1:40 EXCHANGE PL
Practice Address - Street 2:SUITE 728
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-2701
Practice Address - Country:US
Practice Address - Phone:212-425-1060
Practice Address - Fax:646-527-9021
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ21H2Q0241Medicare PIN