1649638677 NPI number — MYRTLE WATSON LICDC

Table of content: MYRTLE WATSON LICDC (NPI 1649638677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649638677 NPI number — MYRTLE WATSON LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
MYRTLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICDC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649638677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 E 89TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44106-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-231-3772
Provider Business Mailing Address Fax Number:
216-231-8826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 E 89TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-231-3772
Provider Business Practice Location Address Fax Number:
216-231-8826
Provider Enumeration Date:
02/04/2016

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: 101YA0400X , with the licence number:  943805 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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