MEDICARE: RUEVINA WATSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1023671831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUEVINA WATSON

Provider Business Mailing Address
First Line	:	1035 W 92ND PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3628
Country	:	US
Telephone Number	:	815-585-5316
Fax Number	:

Provider Business Practice Location Address
First Line	:	1035 W 92ND PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3628
Country	:	US
Telephone Number	:	815-585-5316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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