Provider Demographics
NPI:1750707469
Name:WATT, AUDREY (DPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10881 OAK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-1648
Mailing Address - Country:US
Mailing Address - Phone:619-905-9993
Mailing Address - Fax:
Practice Address - Street 1:10881 OAK CREEK DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-1648
Practice Address - Country:US
Practice Address - Phone:619-905-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40965225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist