Provider Demographics
NPI:1215993647
Name:WATSON, MELODY RENE (PT)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:RENE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:RENE
Other - Last Name:BIMSLAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-579-7100
Mailing Address - Fax:918-579-7110
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-7100
Practice Address - Fax:918-579-7110
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4895225100000X
IL070 006 010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist