Provider Demographics
NPI:1255894366
Name:WATSON, CICELY ANNETTE
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:ANNETTE
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 1:3508 CASTLEHILL CT
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3201
Mailing Address - Country:US
Mailing Address - Phone:678-779-7806
Mailing Address - Fax:
Practice Address - Street 1:2620 SATELLITE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1291
Practice Address - Country:US
Practice Address - Phone:404-785-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0077742251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics