Provider Demographics
NPI:1720326481
Name:WATSON, GRAYSON KOONTZ (MCD, SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:GRAYSON
Middle Name:KOONTZ
Last Name:WATSON
Suffix:
Gender:F
Credentials:MCD, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MCIVER ST
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-1728
Mailing Address - Country:US
Mailing Address - Phone:843-921-1030
Mailing Address - Fax:843-921-1036
Practice Address - Street 1:121 MCIVER ST
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-1728
Practice Address - Country:US
Practice Address - Phone:843-680-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12113169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist