Provider Demographics
NPI:1053664292
Name:WATT, CORINA
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 JAMES RD SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-9356
Mailing Address - Country:US
Mailing Address - Phone:360-273-5161
Mailing Address - Fax:
Practice Address - Street 1:7440 JAMES RD SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WA
Practice Address - Zip Code:98579-9356
Practice Address - Country:US
Practice Address - Phone:360-273-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003469171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT00003469OtherWA STATE BOARD OF HEALTH OT LICENSE NUMBER