Provider Demographics
NPI:1689784613
Name:WATSON, MICHELLE LYNNE (MS PT OCS ATC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNNE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MS PT OCS ATC
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:LYNNE
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PT ATC
Mailing Address - Street 1:16201 PEPPER VIEW CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-532-6167
Mailing Address - Fax:
Practice Address - Street 1:2937 SOUTH BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144
Practice Address - Country:US
Practice Address - Phone:314-961-3804
Practice Address - Fax:314-961-1147
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025159Medicare ID - Type Unspecified