Provider Demographics
NPI:1073238804
Name:WATTS, ADIA (LMT)
Entity type:Individual
Prefix:
First Name:ADIA
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12019 192ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3626
Mailing Address - Country:US
Mailing Address - Phone:347-551-0342
Mailing Address - Fax:
Practice Address - Street 1:156 SCRANTON AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2814
Practice Address - Country:US
Practice Address - Phone:516-321-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01440600225700000X
NY033768-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist