Provider Demographics
NPI:1417095092
Name:WATTS, STEPHANIE (OTR)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WATTS
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 1:925 LAUREL CREST DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6897
Mailing Address - Country:US
Mailing Address - Phone:678-779-0842
Mailing Address - Fax:
Practice Address - Street 1:1050 SHILOH RD NW STE 303
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7197
Practice Address - Country:US
Practice Address - Phone:678-779-0842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003025225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA146018154AMedicaid
GA003025OtherSTATE LICENSE