Basic Information
| Provider Information | |||||||||
| NPI: | 1013989243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON-STITES | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | RYANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WATSON | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | RYANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 EAST 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974035254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413463575 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 EAST 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974035254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413463575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2440 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39143500 | 05 | WI | MEDICAID |