MEDICARE: ANGELA WATSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0400X	Rehabilitation Clinic/Center
2	225X00000X	Occupational Therapist
3	2355S0801X	Speech-Language Assistant
4	235Z00000X	Speech-Language Pathologist
5	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1508110305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA WATSON

Provider Business Mailing Address
First Line	:	4525 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133
Country	:	US
Telephone Number	:	817-822-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6215
Country	:	US
Telephone Number	:	817-822-9195
Fax Number	:

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

Provider Enumeration Date	:	10/31/2012
Last Update Date	:	11/19/2012

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