Provider Demographics
NPI:1639431422
Name:WATSON, ENID (MSC IN EDUCATION)
Entity Type:Individual
Prefix:MRS
First Name:ENID
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSC IN EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2218
Mailing Address - Country:US
Mailing Address - Phone:516-385-0028
Mailing Address - Fax:516-285-1655
Practice Address - Street 1:15 DEWITT ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2218
Practice Address - Country:US
Practice Address - Phone:516-385-0028
Practice Address - Fax:516-285-1655
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7180174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XMedicaid