Provider Demographics
NPI:1982165973
Name:WATSON, GWYN MORGAN
Entity Type:Individual
Prefix:
First Name:GWYN
Middle Name:MORGAN
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 1:104 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-5543
Mailing Address - Country:US
Mailing Address - Phone:770-366-4366
Mailing Address - Fax:
Practice Address - Street 1:105 ARNOLD MILL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5027
Practice Address - Country:US
Practice Address - Phone:770-926-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist