Provider Demographics
NPI:1790259299
Name:WATSON, MICHAEL T
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-5715
Mailing Address - Country:US
Mailing Address - Phone:631-404-0092
Mailing Address - Fax:
Practice Address - Street 1:129 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-5715
Practice Address - Country:US
Practice Address - Phone:631-404-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003789-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer