Provider Demographics
NPI:1912179409
Name:WATSON, MARY BRENT (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRENT
Last Name:WATSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 WHITE DOVE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-3893
Mailing Address - Country:US
Mailing Address - Phone:407-366-6297
Mailing Address - Fax:
Practice Address - Street 1:1525 S ALAFAYA TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8926
Practice Address - Country:US
Practice Address - Phone:407-384-2767
Practice Address - Fax:407-382-5637
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4494235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883958100Medicaid