Basic Information
| Provider Information | |||||||||
| NPI: | 1659388056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 W HOUSTON ST STE B | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740123519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182591888 | ||||||||
| FaxNumber: | 9182513725 | ||||||||
| Practice Location | |||||||||
| Address1: | 536 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744016345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186838555 | ||||||||
| FaxNumber: | 9186838552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3094 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100833760A | 05 | OK | MEDICAID |