Healthcare Provider Details

I. General information

NPI: 1306193073
Provider Name (Legal Business Name): DIANNA LYNN WATSON PT, DPT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2012
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 MURPHY ST
SHREVEPORT LA
71103-2549
US

IV. Provider business mailing address

9882 LOVELAND CT
SHREVEPORT LA
71106-7794
US

V. Phone/Fax

Practice location:
  • Phone: 318-603-6784
  • Fax:
Mailing address:
  • Phone: 318-347-1829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1544
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01919-R
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number1544
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number01919-R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: