Basic Information
| Provider Information | |||||||||
| NPI: | 1386117497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5514 BRANDON PARK DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378044673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652238250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2320 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652738300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2019 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2555 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.