Provider Demographics
NPI:1366512998
Name:WATERS, RENEE LOUISE (CMT)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:LOUISE
Last Name:WATERS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 CRESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6404
Mailing Address - Country:US
Mailing Address - Phone:920-922-8950
Mailing Address - Fax:
Practice Address - Street 1:747 CRESTVIEW LN
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6404
Practice Address - Country:US
Practice Address - Phone:920-922-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist