Healthcare Provider Details

I. General information

NPI: 1770231045
Provider Name (Legal Business Name): LARAVEN S WATERMAN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11375 BIG BEND RD
RIVERVIEW FL
33579-7183
US

IV. Provider business mailing address

14004 ROOSEVELT BLVD STE 613
CLEARWATER FL
33762-3819
US

V. Phone/Fax

Practice location:
  • Phone: 813-805-8167
  • Fax:
Mailing address:
  • Phone: 727-475-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5091
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: