Provider Demographics
NPI:1679233365
Name:WATTS, MICAH JOHN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:JOHN
Last Name:WATTS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 HUNTERS WOODS DR
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-7603
Mailing Address - Country:US
Mailing Address - Phone:570-428-4287
Mailing Address - Fax:
Practice Address - Street 1:97 BOCHICCHIO BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON TWP
Practice Address - State:PA
Practice Address - Zip Code:18444-6695
Practice Address - Country:US
Practice Address - Phone:570-428-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0050562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer