Provider Demographics
NPI:1528001989
Name:WATSON, MARY J (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:WATSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 OAK LANDING DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7607
Mailing Address - Country:US
Mailing Address - Phone:813-988-3600
Mailing Address - Fax:813-684-9632
Practice Address - Street 1:2406 OAK LANDING DRIVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7607
Practice Address - Country:US
Practice Address - Phone:813-988-3600
Practice Address - Fax:813-684-9632
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003625103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75655Medicare ID - Type Unspecified
75655Medicare UPIN