Provider Demographics
NPI:1497048094
Name:WATSON, CAROL MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ALDO CIR
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7998
Mailing Address - Country:US
Mailing Address - Phone:386-366-3890
Mailing Address - Fax:
Practice Address - Street 1:3 CYPRESS PT PKWY STE 108C
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8408
Practice Address - Country:US
Practice Address - Phone:386-366-3890
Practice Address - Fax:386-366-3890
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA8911171W00000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1497048094Medicaid