Basic Information
| Provider Information | |||||||||
| NPI: | 1689784613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS PT OCS ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAMPSON | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS PT ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16201 PEPPER VIEW CT | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365326167 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2937 SOUTH BRENTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149613804 | ||||||||
| FaxNumber: | 3149611147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 113762 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.