Healthcare Provider Details

I. General information

NPI: 1629767306
Provider Name (Legal Business Name): KATIE WELBORN WATKINS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST
RIDGELAND MS
39157-2355
US

IV. Provider business mailing address

100 ELM COURT
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax:
Mailing address:
  • Phone: 601-573-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3772
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: