Provider Demographics
NPI:1992361380
Name:WATSON, RENIKA MARIE
Entity Type:Individual
Prefix:
First Name:RENIKA
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7761 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2739
Mailing Address - Country:US
Mailing Address - Phone:202-424-8637
Mailing Address - Fax:
Practice Address - Street 1:4907 NIAGARA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1100
Practice Address - Country:US
Practice Address - Phone:240-412-2974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-12
Last Update Date:2019-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05247225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty