Basic Information
| Provider Information | |||||||||
| NPI: | 1477658995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHARIS | ||||||||
| OtherFirstName: | SUE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1825 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | FORREST CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723353409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706302328 | ||||||||
| FaxNumber: | 8706302348 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | FORREST CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723353409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706302328 | ||||||||
| FaxNumber: | 8706302348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LSW0000003003 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3922857 | 05 | TN | MEDICAID |