Basic Information
| Provider Information | |||||||||
| NPI: | 1164439477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043554370 | ||||||||
| FaxNumber: | 7043554231 | ||||||||
| Practice Location | |||||||||
| Address1: | 10620 PARK RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046672500 | ||||||||
| FaxNumber: | 7046672507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1455 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7301857 | 05 | NC | MEDICAID | 23315 | 01 | NY | MEDCOST | OTHER | 293421 | 01 | NC | MAMSI | OTHER | 127M5 | 01 | NY | BCBS | OTHER |