MEDICARE: TINA LOU WATSON BSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		CA

General Provider Information

NPI Number	:	1477438760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA LOU WATSON BSW

Provider Business Mailing Address
First Line	:	3628 MADISON AVE STE 6
Second Line	:
City	:	NORTH HIGHLANDS
State	:	CA
Zip	:	95660-5070
Country	:	US
Telephone Number	:	916-969-4805
Fax Number	:

Provider Business Practice Location Address
First Line	:	3628 MADISON AVE STE 6
Second Line	:
City	:	NORTH HIGHLANDS
State	:	CA
Zip	:	95660-5070
Country	:	US
Telephone Number	:	916-388-3231
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2025
Last Update Date	:	02/02/2026

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