Provider Demographics
NPI:1669841706
Name:WATSON, DEIDRE ANNE (PT)
Entity Type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:ANNE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2546
Mailing Address - Country:US
Mailing Address - Phone:817-877-8977
Mailing Address - Fax:817-877-1106
Practice Address - Street 1:1901 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2546
Practice Address - Country:US
Practice Address - Phone:817-877-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1240401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist