Provider Demographics
NPI:1861469512
Name:WATERS, MICHAEL ALAN (LAT, ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:WATERS
Suffix:
Gender:M
Credentials:LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 WILLOW OAK ST
Mailing Address - Street 2:
Mailing Address - City:DIBOLL
Mailing Address - State:TX
Mailing Address - Zip Code:75941-9773
Mailing Address - Country:US
Mailing Address - Phone:936-829-4798
Mailing Address - Fax:
Practice Address - Street 1:309 S. MEDFORD DR.
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-5245
Practice Address - Country:US
Practice Address - Phone:936-632-7656
Practice Address - Fax:936-634-1091
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT0945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist