Provider Demographics
NPI:1316506363
Name:WATSON, CODY (,PT, DPT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:,PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 W NORTH FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4026
Mailing Address - Country:US
Mailing Address - Phone:308-395-7252
Mailing Address - Fax:
Practice Address - Street 1:3213 W NORTH FRONT ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4026
Practice Address - Country:US
Practice Address - Phone:308-395-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist