Provider Demographics
NPI:1811193279
Name:WATSON, MICHELLE ELAINE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELAINE
Last Name:WATSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1055
Mailing Address - Country:US
Mailing Address - Phone:260-908-3565
Mailing Address - Fax:
Practice Address - Street 1:770 N 075 E
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-9359
Practice Address - Country:US
Practice Address - Phone:260-463-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001220A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant