Basic Information
| Provider Information | |||||||||
| NPI: | 1437268638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 N CENTRAL AVE | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063729 | ||||||||
| FaxNumber: | 6027989412 | ||||||||
| Practice Location | |||||||||
| Address1: | 2927 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024065864 | ||||||||
| FaxNumber: | 6024063030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3696 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 093362 | 05 | AZ | MEDICAID |