Healthcare Provider Details

I. General information

NPI: 1104955343
Provider Name (Legal Business Name): MICHELLE R. WATERS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CORNING RD
CARY NC
27518-9229
US

IV. Provider business mailing address

7116 FUGATE CT
RALEIGH NC
27617-7696
US

V. Phone/Fax

Practice location:
  • Phone: 919-431-7400
  • Fax:
Mailing address:
  • Phone: 919-412-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3834
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: