Provider Demographics
NPI:1467954487
Name:WATSON, AMY LYNN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:WATSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 HOADLY RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-3634
Mailing Address - Country:US
Mailing Address - Phone:571-316-6163
Mailing Address - Fax:
Practice Address - Street 1:7405 HOADLY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3634
Practice Address - Country:US
Practice Address - Phone:571-316-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22020006026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid