Provider Demographics
NPI:1790121127
Name:WATSON, LENNIS EZEKIEL (LAT)
Entity Type:Individual
Prefix:MR
First Name:LENNIS
Middle Name:EZEKIEL
Last Name:WATSON
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MELROSE AVE
Mailing Address - Street 2:APT. 1509
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5939
Mailing Address - Country:US
Mailing Address - Phone:318-228-9199
Mailing Address - Fax:318-214-9009
Practice Address - Street 1:501 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6018
Practice Address - Country:US
Practice Address - Phone:318-214-4200
Practice Address - Fax:318-214-9009
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ003472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer