Provider Demographics
NPI:1346755899
Name:WATTS, KEVIN P (D-PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:WATTS
Suffix:
Gender:M
Credentials:D-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:218 S HWY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1677
Practice Address - Country:US
Practice Address - Phone:715-854-7761
Practice Address - Fax:715-854-7785
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14088-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14088-24OtherWISCONSIN LICENSE