Healthcare Provider Details

I. General information

NPI: 1205986064
Provider Name (Legal Business Name): ALTHEA G. WATSON M.AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BIG LEAF CIR
COLUMBIA SC
29229-9182
US

IV. Provider business mailing address

104 BIG LEAF CIR
COLUMBIA SC
29229-9182
US

V. Phone/Fax

Practice location:
  • Phone: 803-736-5756
  • Fax:
Mailing address:
  • Phone: 803-736-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number515
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: