1689784613 NPI number — MRS. MICHELLE LYNNE WATSON MS PT OCS ATC

Table of content: MRS. CYNTHIA KELLY MA (NPI 1548501067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689784613 NPI number — MRS. MICHELLE LYNNE WATSON MS PT OCS ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
MICHELLE
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS PT OCS ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMPSON
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS PT ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689784613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16201 PEPPER VIEW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-532-6167
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2937 SOUTH BRENTWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-961-3804
Provider Business Practice Location Address Fax Number:
314-961-1147
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  113762 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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