Provider Demographics
NPI:1619283884
Name:WATSON, MELISSA A
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 MARYLAND RD
Mailing Address - Street 2:APT F-11
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1850
Mailing Address - Country:US
Mailing Address - Phone:215-392-4858
Mailing Address - Fax:
Practice Address - Street 1:614 N EASTON RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-4301
Practice Address - Country:US
Practice Address - Phone:267-385-8672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-5235103K00000X
PAPC006372101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst