Provider Demographics
NPI:1285959478
Name:WATTERSON, GREG G (LMT)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:G
Last Name:WATTERSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 STURBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7907
Mailing Address - Country:US
Mailing Address - Phone:850-212-4688
Mailing Address - Fax:
Practice Address - Street 1:3521 MACLAY BLVD S
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-3913
Practice Address - Country:US
Practice Address - Phone:850-431-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 53580175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath