Provider Demographics
NPI:1790064822
Name:WATSON, ANDREA ROSE (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 BRASELTON HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5906
Mailing Address - Country:US
Mailing Address - Phone:770-904-0772
Mailing Address - Fax:770-904-0774
Practice Address - Street 1:3615 BRASELTON HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5906
Practice Address - Country:US
Practice Address - Phone:770-904-0772
Practice Address - Fax:770-904-0774
Is Sole Proprietor?:No
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002825225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant