Provider Demographics
NPI:1558915686
Name:WATTS, KYLE JACOB (LMT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JACOB
Last Name:WATTS
Suffix:
Gender:M
Credentials:LMT
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 73369
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0369
Mailing Address - Country:US
Mailing Address - Phone:253-970-8256
Mailing Address - Fax:253-604-4450
Practice Address - Street 1:8112 112TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7815
Practice Address - Country:US
Practice Address - Phone:253-970-8256
Practice Address - Fax:253-604-4450
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60079928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist