Provider Demographics
NPI:1063860153
Name:WATTS, RENITA (MA38720)
Entity Type:Individual
Prefix:MISS
First Name:RENITA
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:MA38720
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 CLARK RD APT 226
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8489
Mailing Address - Country:US
Mailing Address - Phone:941-735-9671
Mailing Address - Fax:
Practice Address - Street 1:5602 MARQUESAS CIR
Practice Address - Street 2:206
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-3310
Practice Address - Country:US
Practice Address - Phone:941-735-9671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38720225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist