Provider Demographics
NPI:1609266501
Name:WATSON, RANDAL (LMP)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 S OTHELLO ST # 100-203
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3510
Mailing Address - Country:US
Mailing Address - Phone:936-697-2061
Mailing Address - Fax:
Practice Address - Street 1:409 15TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4504
Practice Address - Country:US
Practice Address - Phone:360-830-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60483853225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist