Healthcare Provider Details

I. General information

NPI: 1376091256
Provider Name (Legal Business Name): LACRISHA WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 GRAVOIS AVE
SAINT LOUIS MO
63118-1543
US

IV. Provider business mailing address

3002 S JEFFERSON AVE
SAINT LOUIS MO
63118-1513
US

V. Phone/Fax

Practice location:
  • Phone: 314-922-6398
  • Fax:
Mailing address:
  • Phone: 314-991-1495
  • Fax: 314-881-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number371586570
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: