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General NPI Number Information
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NPI Number | 1619239894
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Entity Type | Individual
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Provider Name | ANGELA MARIE WATTERS M.S., CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 06/13/2012
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Last Update Date | 04/24/2023
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Provider Practice Location Address
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Address Line | 2122 TROY RD STE 120
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-2540
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Country | US
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Telephone | 618-800-4620
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Fax |
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Provider Business Mailing Address
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Address Line | 2122 TROY RD STE 120
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-2540
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Country | US
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Telephone | 618-800-4620
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA11936
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License Number State | FL
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