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

Table of content: MRS. MICHELLE LYNNE WATSON MS PT OCS ATC (NPI 1689784613)

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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