Provider Demographics
NPI:1710124581
Name:WATSON, MALIA A (MSPT)
Entity Type:Individual
Prefix:MS
First Name:MALIA
Middle Name:A
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2272
Mailing Address - Country:US
Mailing Address - Phone:607-771-8181
Mailing Address - Fax:607-772-2899
Practice Address - Street 1:17 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2272
Practice Address - Country:US
Practice Address - Phone:607-771-8181
Practice Address - Fax:607-772-2899
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020275-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist