Provider Demographics
NPI:1922010875
Name:WATSON, MITCHELL DEANE (OWNER)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DEANE
Last Name:WATSON
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:MITCHELL
Other - Middle Name:DEANE
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OWNER
Mailing Address - Street 1:7810 CERVIN DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79121-1206
Mailing Address - Country:US
Mailing Address - Phone:806-467-1115
Mailing Address - Fax:806-359-1517
Practice Address - Street 1:3000 BLACKBURN ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1760
Practice Address - Country:US
Practice Address - Phone:806-359-1414
Practice Address - Fax:806-359-1517
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1138253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160306001Medicaid
TX160306001Medicaid