Basic Information
| Provider Information | |||||||||
| NPI: | 1700017704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | MICHAELA | ||||||||
| MiddleName: | PRICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRICE | ||||||||
| OtherFirstName: | MICHAELA | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 210 TIMBER COURT DR APT B | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370438835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312066408 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 UFFELMAN DR STE F | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370432970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319207330 | ||||||||
| FaxNumber: | 9319207331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 08/07/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.