Healthcare Provider Details

I. General information

NPI: 1003804410
Provider Name (Legal Business Name): NORMAN DANIEL WATHEN ATC ;CSCS;NSCA-CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 SAMPSON DR
GIRARD OH
44420-3504
US

IV. Provider business mailing address

5301 SAMPSON DR
GIRARD OH
44420-3504
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-2314
  • Fax: 330-941-3191
Mailing address:
  • Phone: 330-759-2314
  • Fax: 330-941-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-174
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: