Healthcare Provider Details

I. General information

NPI: 1780595611
Provider Name (Legal Business Name): BRIANNA WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10419 CALUMET AVE STE B
MUNSTER IN
46321-4059
US

IV. Provider business mailing address

1055 187TH ST
HOMEWOOD IL
60430-4137
US

V. Phone/Fax

Practice location:
  • Phone: 219-491-1759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: