MEDICARE: MELANIE GLASS WATTERS DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	23143	FL
2	225100000X	Physical Therapist	PTH6021	AL
3	225100000X	Physical Therapist	PT10084	AZ

General Provider Information

NPI Number	:	1255484580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE GLASS WATTERS DPT

Provider Business Mailing Address
First Line	:	2342 MONGWA OVI
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86005-3531
Country	:	US
Telephone Number	:	205-531-5834
Fax Number	:

Provider Business Practice Location Address
First Line	:	2342 MONGWA OVI
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86005-3531
Country	:	US
Telephone Number	:	205-531-5834
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	04/09/2014

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