Basic Information
| Provider Information | |||||||||
| NPI: | 1447359757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LASHUN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C5643 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 557 GRANT FERRY RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016654162 | ||||||||
| FaxNumber: | 8558303484 | ||||||||
| Practice Location | |||||||||
| Address1: | 1911 MISSION 66 STE B | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391803762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016654162 | ||||||||
| FaxNumber: | 8558303484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M5643 | MS | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C5643 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.