Provider Demographics
NPI:1073574109
Name:WATSON, ELIZABETH LAX (OTR)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LAX
Last Name:WATSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15446 ABBOTTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2182
Mailing Address - Country:US
Mailing Address - Phone:704-577-1091
Mailing Address - Fax:
Practice Address - Street 1:9129 MONROE RD
Practice Address - Street 2:SUITE 100-105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2429
Practice Address - Country:US
Practice Address - Phone:704-847-3911
Practice Address - Fax:704-847-2033
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2483225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301496Medicaid